{ "hospital_name": "San Dimas Community Hospital", "last_updated_on": "2026-03-17", "version": "3.0", "location_name": [ "San Dimas Community Hospital" ], "hospital_address": [ "1350 West Covina Boulevard San Dimas, CA 91773" ], "license_information": { "license_number": "262583397", "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": "Parrish Scarboro" }, "type_2_npi": [ "1740447945" ], "standard_charge_information": [ { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "Ablate inf turbinate submuc", "code_information": [ { "code": "30802", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7885.41, "discounted_cash": 1985, "minimum": 117.49, "maximum": 7885.41, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2537.51, "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": 117.49 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2025.53, "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": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2223.61, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1967.28 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 117.49 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 2978.72, "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": 2005.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2616.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2780.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "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": 1985.81, "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 $6490", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 1268.37, "10th_percentile": 1268.37, "90th_percentile": 1268.37, "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": 2792.05, "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": 2899.28, "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": 125.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2581.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2482.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 117.49 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2104.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 117.49 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 117.49 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2581.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2581.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1886.52, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 117.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2616.01, "additional_payer_notes": "131.74% 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 2", "code_information": [ { "code": "2512", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5154.21, "maximum": 5515, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 1", "code_information": [ { "code": "5431", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4539.67, "maximum": 4857.45, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITHOUT D&C", "code_information": [ { "code": "779", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8123, "minimum": 5200, "maximum": 48414.572, "payers_information": [ { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12184.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8123.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5399.65 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14379.5 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13948.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8166.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16150.76, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 12874.94 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8123.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9690.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8086.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14091.91 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10559.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8123.04, "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": 8123.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14718.95, "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": 11420.99, "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": 11859.64, "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": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10559.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10153.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8486.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8123.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8123.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12996.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10559.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.95, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY", "code_information": [ { "code": "770", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9635, "minimum": 5200, "maximum": 17458.6744, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16054.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9685.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13040.45, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8866.32 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9635.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11550.1 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9590.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16220.47 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12525.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9635.03, "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": 9635.03, "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": 17458.67, "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": 13546.85, "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": 14067.14, "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": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12525.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12043.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10065.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9635.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9635.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15416.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12525.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14452.55, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9635.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10048.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9495.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16551.5 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "ACUTE AND SUBACUTE ENDOCARDITIS WITH CC", "code_information": [ { "code": "289", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16231, "minimum": 9065.34, "maximum": 29412.3478, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23525.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16314.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24126.54, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 18761.01 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16231.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19661.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16154.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23768.43 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 21101.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16231.98, "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": 16231.98, "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": 29412.35, "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": 22822.16, "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": 23698.69, "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": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 21101.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20289.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16954.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16231.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16231.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25971.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 21101.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 24347.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16231.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9065.34 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24253.5 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 1", "code_information": [ { "code": "1931", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8140.51, "maximum": 8710.35, "payers_information": [ { "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" }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 3", "code_information": [ { "code": "1933", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13200.37, "maximum": 14124.4, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC", "code_information": [ { "code": "288", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25593, "minimum": 21830, "maximum": 46375.277, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40756.68 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25721.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42336.14, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 29964.84 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 25593.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 31172.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 25468.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 41176.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 33271.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 25593.42, "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": 25593.42, "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": 46375.28, "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": 35984.35, "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": 37366.39, "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": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 33271.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31991.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26729.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25593.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25593.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40949.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 33271.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 38390.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25593.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35197.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 25216.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42017.2 } ] } ] }, { "description": "ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION", "code_information": [ { "code": "880", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9236, "minimum": 7732.8, "maximum": 16737.2447, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14303.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9285.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15585.84, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9662.4 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9236.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11060.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9194.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14450.69 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12007.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9236.89, "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": 9236.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16737.24, "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": 12987.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13485.86, "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": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12007.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11546.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9649.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9236.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9236.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14779.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12007.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13855.34, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9236.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7732.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14745.6 } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CCMCC", "code_information": [ { "code": "290", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8951, "minimum": 8821.77, "maximum": 25316.536, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14607.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8998.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17716.52, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11282.77 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8951.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10709.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8909.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14758.21 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11636.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8951.17, "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": 8951.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16219.52, "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": 12585.35, "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": 13068.71, "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": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11636.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11188.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9351.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8951.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8951.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14321.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11636.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13426.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8951.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12792.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15059.4 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 2", "code_information": [ { "code": "4692", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5463.76, "maximum": 5846.22, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 MAJOR EYE INFECTIONS WITH CCMCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11139, "minimum": 5683.35, "maximum": 26091.532, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17356.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11197.15, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20918.27, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 14295.71 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11139.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13400.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11087.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17535.04 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14481.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11139.53, "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": 11139.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20184.83, "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": 15662.18, "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": 16263.71, "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": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14481.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13924.41, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11636.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11139.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11139.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17823.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14481.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16709.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11139.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5683.35 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10977.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17892.9 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 WITHOUT CCMCC", "code_information": [ { "code": "836", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11666, "minimum": 7080, "maximum": 94740.796, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11666.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11666.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18665.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15165.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17499.03, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11666.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16603.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19546.5 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18960.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11726.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23052.22, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 14857.26 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11666.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14047.42 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11611.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19155.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 15165.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11666.02, "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": 11666.02, "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": 21138.83, "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": 16402.42, "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": 17032.39, "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": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15165.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14582.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11496.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12186.08, "additional_payer_notes": "106.00% 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 MAJOR EYE INFECTIONS WITHOUT CCMCC", "code_information": [ { "code": "122", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7603, "minimum": 3644.5, "maximum": 15141.016, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10120.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7643.63, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12155.52, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8711.84 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7603.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9051.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7568.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10225.22 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9884.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7603.11, "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": 7603.11, "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": 13776.84, "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": 10689.97, "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": 11100.54, "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": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9884.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9503.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7943.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7603.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7603.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12164.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9884.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11404.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7603.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 3644.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7493.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10433.9 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 2", "code_information": [ { "code": "1902", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7316.81, "maximum": 7828.99, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC", "code_information": [ { "code": "281", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8851, "minimum": 7080, "maximum": 16039.5884, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13754.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8898.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14906.63, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 10923.06 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8851.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10587.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8811.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13896.01 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11507.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8851.87, "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": 8851.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16039.59, "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": 12445.73, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12923.73, "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": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11507.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11064.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9247.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8851.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8851.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14162.99, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11507.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13277.81, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8851.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12089.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8723.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14179.6 } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC", "code_information": [ { "code": "835", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19781, "minimum": 12980, "maximum": 36499.21, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31869.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19881.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36499.21, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 22869.98 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19781.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24026.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19686.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32198.29 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 25715.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19781.51, "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": 19781.51, "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": 35844.1, "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": 27812.8, "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": 28881, "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": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 25715.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24726.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20660.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19781.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19781.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31650.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25715.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 29672.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19781.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23755.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32855.4 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC", "code_information": [ { "code": "280", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15268, "minimum": 12095, "maximum": 27667.3374, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24491.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15346.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25902.93, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 18390.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15268.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18477.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15196.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24743.82 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 19849.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15268.95, "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": 15268.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27667.34, "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": 21468.14, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22292.67, "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": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 19849.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19086.19, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15948.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15268.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15268.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24430.32, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19849.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 22903.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15268.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17932.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15045.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25248.8 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CCMCC", "code_information": [ { "code": "282", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7015, "minimum": 5015, "maximum": 39061.376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10819.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7053.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11724.48, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8320.56 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7015.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8329.39 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6984.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10930.72 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9120.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7015.74, "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": 7015.74, "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": 12712.52, "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": 9864.13, "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": 10242.98, "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": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9120.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8769.68, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7330.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7015.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7015.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11225.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9120.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10523.61, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7015.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10844 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11153.8 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC", "code_information": [ { "code": "834", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 51671, "minimum": 27730, "maximum": 107200, "payers_information": [ { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53961.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 51671.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 51671.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 82673.79, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 67172.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 77506.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 51671.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 107200 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85023.6 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 82472.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 51925.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91415.37, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 65880.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 51671.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 63238.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 51416.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 83323.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 67172.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 51671.12, "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": 51671.12, "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": 93628.07, "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": 72649.59, "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": 75439.84, "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": 50907, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 67172.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 64588.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 50907, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18797, "minimum": 9440, "maximum": 34061.7404, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29176.53 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18892.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32187.22, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 20293.42 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18797.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22816.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18707.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29477.32 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24437.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18797.87, "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": 18797.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34061.74, "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": 26429.81, "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": 27444.89, "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": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 24437.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23497.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19633.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18797.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18797.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30076.59, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 24437.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 28196.81, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18797.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33286.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18522.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30078.9 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC", "code_information": [ { "code": "284", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6726, "minimum": 4720, "maximum": 12188.0012, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11056.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6762.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12077.15, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8178.48 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6726.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7973.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6696.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11170.43 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8744.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6726.27, "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": 6726.27, "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": 12188, "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": 9457.14, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9820.35, "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": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8744.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8407.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7027.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6726.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6726.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10762.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8744.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10089.41, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6726.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9682.17 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11398.4 } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "615", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13350, "minimum": 4425, "maximum": 68771.528, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21381.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13418.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24018.78, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 16734.71 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13350.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16118.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13287.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21602.24 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17355.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13350.38, "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": 13350.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24190.89, "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": 18770.63, "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": 19491.55, "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": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17355.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16687.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13944.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13350.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13350.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21360.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17355.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20025.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13350.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19407.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13155.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22043.1 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITH CCMCC", "code_information": [ { "code": "614", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20774, "minimum": 7965, "maximum": 37643.4302, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34355.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 27006.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20774.52, "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": 20774.52, "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": 37643.43, "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": 29208.98, "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": 30330.8, "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": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 27006.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25968.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21697.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20774.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20774.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33239.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 27006.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 31161.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20774.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32003.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35056.7 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34005 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20878.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36775.14, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20469.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 27437.89 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20774.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 25247.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20674.2, "additional_payer_notes": "101.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CCMCC", "code_information": [ { "code": "285", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5852, "minimum": 3835, "maximum": 43636.416, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8376.63 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 5884.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7979.05, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 5838.71 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 5852.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 6898.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 5826.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 8462.99 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7607.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 5852.24, "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": 5852.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10604.26, "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": 8228.25, "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": 8544.27, "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": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 7607.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 7315.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6115.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 5852.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5852.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9363.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 7607.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8778.36, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5852.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7336.09 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 5768.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8635.7 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10791, "minimum": 10634.3, "maximum": 19553.3645, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16990.52 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10846.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18483.9, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11766.51 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10791.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12971.55 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10740.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17165.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14028.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10791.04, "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": 10791.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19553.36, "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": 15172.2, "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": 15754.92, "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": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14028.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13488.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11272.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10791.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10791.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17265.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14028.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16186.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10791.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18360.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10634.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17516 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE WITH CCMCC", "code_information": [ { "code": "949", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11386, "minimum": 11140.4196, "maximum": 29038.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16099.77 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11445.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17515.7, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 12278.44 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11386.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13704.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11333.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16265.75 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14802.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11386.85, "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": 11386.85, "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": 20632.97, "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": 16009.91, "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": 16624.8, "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": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14802.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14233.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11894.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11386.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11386.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18218.96, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14802.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17080.28, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11386.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29038.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11221.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16597.7 } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "561", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7772, "minimum": 7660.79, "maximum": 28097.056, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12199.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7814.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12738.39, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8427.68 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7772.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9260.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7737.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12325.17 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10104.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7772.68, "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": 7772.68, "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": 14084.1, "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": 10928.39, "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": 11348.11, "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": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10104.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9715.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8120.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7772.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7772.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12436.29, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10104.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11659.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7772.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11761 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7660.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12576.7 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "559", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17712, "minimum": 15045, "maximum": 32094.3614, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27697.87 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17801.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30213.28, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 20317.1 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17712.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21481.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17627.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27983.41 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23025.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17712.12, "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": 17712.12, "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": 32094.36, "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": 24903.24, "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": 25859.7, "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": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23025.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22140.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18499.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17712.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17712.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28339.39, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23025.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26568.18, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17712.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24255.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17452.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28554.5 } ] } ] }, { "description": "AICD GENERATOR PROCEDURES", "code_information": [ { "code": "245", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42982, "minimum": 12685, "maximum": 77883.9276, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72915.97 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 43194.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 73984.57, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 58723.15 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 42982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 52554.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 42770.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 73667.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 55876.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 42982.3, "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": 42982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 77883.93, "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": 60433.11, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 62754.16, "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": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 55876.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 53727.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44888.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 42982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 68771.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 55876.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 64473.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 63852.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 42347.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75171.1 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY", "code_information": [ { "code": "895", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13503, "minimum": 8663.93, "maximum": 35499.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21604.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13572.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26267.02, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 18344.92 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13503.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16306.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13439.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21826.85 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17554, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13503.08, "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": 13503.08, "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": 24467.58, "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": 18985.33, "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": 19714.5, "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": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17554, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16878.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14104.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13503.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13503.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21604.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17554, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20254.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13503.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8663.93 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13306.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22272.3 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC", "code_information": [ { "code": "896", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16589, "minimum": 13799.9, "maximum": 30060.7901, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26571.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16673.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29031.2, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 19391.34 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16589.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 20101.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16510.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26845.24 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 21566.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16589.84, "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": 16589.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30060.79, "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": 23325.32, "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": 24221.17, "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": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 21566.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20737.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17327.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16589.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16589.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26543.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 21566.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 24884.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16589.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13799.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16347, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27393.1 } ] } ] }, { "description": "AFTERCARE WITHOUT CCMCC", "code_information": [ { "code": "950", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6122, "minimum": 6034.67, "maximum": 23183.1, "payers_information": [ { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9795.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 7958.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9183.05, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6122.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23183.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9015.7 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8745.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6155.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10426.48, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8354.39 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6122.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7230.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6095.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 8835.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7958.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6122.03, "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": 6122.03, "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": 11093.12, "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": 8607.57, "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": 8938.16, "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": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 7958.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 7652.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6396.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6122.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6122.03, "additional_payer_notes": "100.00% 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA", "code_information": [ { "code": "894", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6020, "minimum": 4541.5, "maximum": 10909.7983, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9312.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6053.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9379.91, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 6544.59 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6020.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7106.07 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 5994.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9408.2 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7827.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6020.86, "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": 6020.86, "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": 10909.8, "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": 8465.33, "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": 8790.46, "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": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 7827.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 7526.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6291.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6020.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6020.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9633.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 7827.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9031.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6020.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4541.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 5935, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9600.2 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC", "code_information": [ { "code": "897", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8511, "minimum": 8388.94, "maximum": 15423.3997, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13163.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8556.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13969.46, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9266.62 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8511.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10168.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8472.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13298.99 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11065.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8511.81, "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": 8511.81, "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": 15423.4, "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": 11967.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12427.24, "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": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11065.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10639.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8892.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8511.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8511.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13618.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11065.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12767.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8511.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8388.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13570.4 } ] } ] }, { "description": "AICD LEAD PROCEDURES", "code_information": [ { "code": "265", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34137, "minimum": 12095, "maximum": 120852.048, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53226.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 34306.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57701.57, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 35195.78 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 34137.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 41678.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33969.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 53774.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 44378.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 34137.04, "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": 34137.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 61856.32, "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": 47996.68, "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": 49840.08, "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": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 44378.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 42671.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35651.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 34137.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34137.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 54619.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 44378.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 51205.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34137.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46611 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 33633.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54872.4 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "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": 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15994, "minimum": 10915, "maximum": 28982.8856, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25931.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16076.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28964.26, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 19159.05 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15994.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19370.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15918.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26198.54 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20793.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15994.97, "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": 15994.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28982.89, "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": 22488.93, "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": 23352.66, "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": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20793.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19993.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16706.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15994.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15994.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25591.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20793.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23992.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15994.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18126 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15760.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26733.2 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "ALLOGENEIC BONE MARROW TRANSPLANT", "code_information": [ { "code": "014", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 112825, "minimum": 81420, "maximum": 204439.6792, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 146673.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 141031.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 117822.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 112825.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 112825.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 180520.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 146673.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 169238.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 112825.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 138261 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 201538.1 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 195491.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 113376.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 187123.13, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 143823.12 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 112825.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 138434.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 112264.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 197507.34 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 146673.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 111153, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 112825.43, "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": 112825.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 204439.68, "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": 158632.55, "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": 164725.13, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 4", "code_information": [ { "code": "8114", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15162.61, "maximum": 16223.99, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITHOUT MCC", "code_information": [ { "code": "916", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6483, "minimum": 5199.54, "maximum": 30928.848, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9909.04 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6518.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10756.29, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 7139.96 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6483.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7675.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10011.19 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8428.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6483.64, "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": 6483.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11748.36, "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": 9116, "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": 9466.11, "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": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8428.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8104.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6774.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6483.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6483.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10373.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8428.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9725.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6483.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5199.54 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6390.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10215.5 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "ANAL AND STOMAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "349", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8397, "minimum": 5015, "maximum": 30063.14, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13143.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8441.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15931.97, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11060.63 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8397.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10028.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8359.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13279.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10916.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8397.52, "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": 8397.52, "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": 15216.31, "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": 11806.91, "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": 12260.38, "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": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10916.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10496.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8772.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8397.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8397.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13436.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10916.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12596.28, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8397.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8687.47 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13550.4 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 3", "code_information": [ { "code": "0523", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9100.96, "maximum": 9738.03, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC", "code_information": [ { "code": "239", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 46348, "minimum": 33335, "maximum": 83982.9928, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75155.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 46576.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78481.05, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 52655.54 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 46348.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 56693.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 46119.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 75930.4 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 60252.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 46348.23, "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": 46348.23, "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": 83982.99, "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": 65165.61, "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": 67668.42, "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": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 60252.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 57935.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 48402.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 46348.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46348.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 74157.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 60252.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 69522.35, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46348.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46585.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 45663.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77480 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "475", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21560, "minimum": 16815, "maximum": 44876.804, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32189.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21668.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35016.71, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 23690.88 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21560.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 26213.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21456.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32520.91 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 28028.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21560.5, "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": 21560.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39067.63, "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": 30314.06, "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": 31478.33, "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": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 28028.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26950.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22518.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21560.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21560.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34496.8, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 28028.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 32340.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21560.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24613.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 21243.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33184.6 } ] } ] }, { "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": 13210, "minimum": 12980, "maximum": 62962.016, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22529.22 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13278.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22759.96, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 17097.8 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13210.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15946.9 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13148.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22761.48 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17174.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13210.8, "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": 13210.8, "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": 23937.97, "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": 18574.38, "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": 19287.77, "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": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17174.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16513.5, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13799.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13210.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13210.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21137.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17174.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 19816.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13210.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19729.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13018.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23226 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "476", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11297, "minimum": 7375, "maximum": 23273.544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17354.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11356.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19215.35, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 13133.16 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11297.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13594.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11244.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17533.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14687.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11297.85, "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": 11297.85, "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": 20471.7, "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": 15884.78, "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": 16494.86, "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": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14687.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14122.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11801.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11297.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11297.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18076.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14687.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16946.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11297.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10128.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11133.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17891.4 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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": 26945, "minimum": 21535, "maximum": 48824.7386, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43452.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 27079.47, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45866.06, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 31121.76 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 26945.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 32834.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 26813.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 43900.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 35028.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 26945.22, "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": 26945.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 48824.74, "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": 37884.98, "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": 39340.02, "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": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 35028.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 33681.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 28141.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 26945.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26945.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 43112.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 35028.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 40417.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26945.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24532.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 26548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44796.8 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Amputation Toe & Metatarsal", "code_information": [ { "code": "28810", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13000, "discounted_cash": 4187, "minimum": 363.13, "maximum": 13000, "payers_information": [ { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2576.58 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 363.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 381.29 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4689.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "474", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40457, "minimum": 30090, "maximum": 84655.988, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66916.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 40657.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70252.2, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 43693.37 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 40457.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 49449.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 40258.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 67606.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 52594.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 40457.63, "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": 40457.63, "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": 73309.23, "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": 56883.43, "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": 59068.14, "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": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 52594.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 50572.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42251.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 40457.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40457.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 64732.21, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 52594.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 60686.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40457.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 67903.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 39860.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68985.8 } ] } ] }, { "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": 32911, "minimum": 28902.9, "maximum": 64617.72, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57669.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 33074.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64617.72, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 45113.02 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 32911.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 40171.36 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 32750.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 58264.23 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 42785.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 32911.7, "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": 32911.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 59636, "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": 46273.85, "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": 48051.08, "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": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 42785.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 41139.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34371.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 32911.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32911.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 52658.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 42785.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 49367.55, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32911.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28902.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 32426.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59453.3 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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": "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 Healthcare", "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" }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Amputation Of Toe", "code_information": [ { "code": "28820", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12500, "discounted_cash": 4187, "minimum": 327.36, "maximum": 12500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 327.36 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 343.73 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4689.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2576.58 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 350.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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": 17762, "minimum": 16815, "maximum": 32401.11, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28821.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17852.45, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32401.11, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 23130.46 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17762.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21543.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17677.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29118.54 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23091.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17762.71, "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": 17762.71, "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": 32186.03, "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": 24974.37, "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": 25933.56, "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": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23091.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22203.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18552.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17762.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17762.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28420.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23091.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26644.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17762.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17894.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17502.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29712.8 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "Av fusion direct any site", "code_information": [ { "code": "36821", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30000, "discounted_cash": 4041, "minimum": 623.2, "maximum": 30000, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.85, "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": 623.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4121.96, "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": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 654.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4525.06, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4784.68 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 666.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5253.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5253.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5253.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3839.08, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 30000, "discounted_cash": 4041, "minimum": 623.2, "maximum": 30000, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.85, "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": 623.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4121.96, "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": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 654.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4525.06, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4784.68 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 666.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5253.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5253.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5253.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3839.08, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 623.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare 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": 13528, "minimum": 12390, "maximum": 56939.528, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18578.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13597.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18963.91, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 14145.74 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13528.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16337.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13464.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18769.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17586.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13528.37, "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": 13528.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24513.41, "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": 19020.89, "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": 19751.42, "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": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17586.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16910.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14130.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13528.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13528.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21645.39, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17586.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20292.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13528.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16269.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13331, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19152.7 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "520", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14236, "minimum": 5900, "maximum": 56600.344, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21384.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14309.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23372.23, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15087.29 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14236.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 17208.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14168.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21605.28 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 18507.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14236.6, "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": 14236.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25796.72, "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": 20016.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20785.44, "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": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 18507.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17795.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14870.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14236.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14236.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22778.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18507.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 21354.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14236.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20552.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14028.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22046.2 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 2", "code_information": [ { "code": "0592", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7339.07, "maximum": 7852.8, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "ANAL AND STOMAL PROCEDURES WITH CC", "code_information": [ { "code": "348", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12502, "minimum": 9145, "maximum": 49140.268, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18784.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12566.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21248.07, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15891.27 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12502.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15076.07 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12443.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18977.7 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 16253.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12502.58, "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": 12502.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22654.67, "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": 17578.63, "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": 18253.77, "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": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16253.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15628.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13059.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12502.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12502.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20004.13, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16253.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 18753.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12502.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15818.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19365 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "ANAL AND STOMAL PROCEDURES WITH MCC", "code_information": [ { "code": "347", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21746, "minimum": 15451.4088, "maximum": 41619.38, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21746.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30925.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36407.2 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35314.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21855.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41619.38, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 29728.05 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 21746.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 26443.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21641.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 35679.06 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 28271, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21746.92, "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": 21746.92, "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": 39405.42, "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": 30576.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31750.5, "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": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 28271, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27183.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22713.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21746.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21746.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34795.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 28271, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 32620.38, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21427.4, "additional_payer_notes": "100.00% of Medicare 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": 39804, "minimum": 4425, "maximum": 104048.636, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62081.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 40001.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67897.83, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 48107.93 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 39804.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 48647.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 39609.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 62721.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 51746.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 39804.68, "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": 39804.68, "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": 72126.08, "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": 55965.38, "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": 58114.83, "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": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 51746.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 49755.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41569.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 39804.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 39804.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 63687.49, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 51746.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 59707.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 39804.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8074.17 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 39216.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64001.9 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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": 33644, "minimum": 22125, "maximum": 70313.632, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52242.94 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 33810.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60772.69, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 40183.15 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 33644.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 41072.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33479.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 52781.53 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 43737.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 33644.28, "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": 33644.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 60963.44, "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": 47303.86, "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": 49120.65, "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": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 43737.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 42055.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35136.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33644.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33644.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53830.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 43737.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 50466.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33644.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 68656.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 33148, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53858.7 } ] } ] }, { "description": "ANGINA PECTORIS", "code_information": [ { "code": "311", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6817, "minimum": 5900, "maximum": 41120.144, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10419.35 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6853.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11397.94, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 7724.06 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6817.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8085.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6786.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10526.77 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8862.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6817.14, "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": 6817.14, "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": 12352.66, "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": 9584.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9953.02, "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": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8862.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8521.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7122.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6817.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6817.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10907.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8862.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10225.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7771.64 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6719.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10741.6 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "Application of long arm cast", "code_information": [ { "code": "29065", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16250, "discounted_cash": 357, "minimum": 132.97, "maximum": 16250, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "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": 132.97 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 365.13, "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": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 139.62 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 400.84, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 299.18 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 536.96, "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": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 465.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 447.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 379.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 465.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 465.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 340.07, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 16250, "discounted_cash": 357, "minimum": 132.97, "maximum": 16250, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "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": 132.97 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 365.13, "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": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 139.62 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 400.84, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 299.18 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 536.96, "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": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 465.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 447.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 379.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 465.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 465.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 340.07, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "BIOPSY OF CERVIX", "code_information": [ { "code": "57500", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4700, "discounted_cash": 1178, "minimum": 58.15, "maximum": 4700, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1506.32, "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": 58.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.4, "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": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.06 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1319.98, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 787.6 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1768.23, "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": 1190.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1552.92, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1650.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "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": 1178.82, "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": 1657.42, "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": 1721.08, "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": 62.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1532.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1473.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1249.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1532.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1532.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1119.88, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1552.92, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 4700, "discounted_cash": 1178, "minimum": 58.15, "maximum": 4700, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1768.23, "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": 1190.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1552.92, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1650.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "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": 1178.82, "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": 1657.42, "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": 1721.08, "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": 62.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1532.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1473.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1249.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1532.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1532.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1119.88, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1552.92, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1506.32, "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": 58.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.4, "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": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.06 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1319.98, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 787.6 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1178.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.15 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "ARTHROSCOPY", "code_information": [ { "code": "509", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11800, "maximum": 59564.26, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26211.73 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22304.44, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15692.81 }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26481.95 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22953.5 }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27022.4 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "APPENDIX PROCEDURES WITH CC", "code_information": [ { "code": "398", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14421, "minimum": 8850, "maximum": 30786.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22578.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14494.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24707.78, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14421.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 17435.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14352.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22811.26 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 18747.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14421.14, "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": 14421.14, "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": 26131.11, "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": 20276.12, "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": 21054.86, "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": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 18747.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18026.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15063.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14421.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14421.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23073.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18747.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 21631.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14421.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30786.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14210.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23276.8 } ] } ] }, { "description": "Arthrp ntrcrpl/crp/mtcrp ssp", "code_information": [ { "code": "25448", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21000, "discounted_cash": 4187, "minimum": 2061, "maximum": 21000, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 4271.46, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4689.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 21000, "discounted_cash": 4187, "minimum": 2061, "maximum": 21000, "payers_information": [ { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 4271.46, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4689.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITHOUT MCC", "code_information": [ { "code": "554", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8018, "minimum": 6547.39, "maximum": 26065.896, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12453.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8060.63, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13417.6, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8876.47 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8018.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9561.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12581.44 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10423.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8018.12, "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": 8018.12, "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": 14528.83, "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": 11273.48, "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": 11706.46, "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": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10423.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10022.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8376.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8018.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8018.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12828.99, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10423.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12027.18, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8018.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6547.39 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7902.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12838.2 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "Apply handwrist cast", "code_information": [ { "code": "29085", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8666.66, "discounted_cash": 207, "minimum": 119.63, "maximum": 8666.66, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "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": 119.63 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 212.14, "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": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 125.61 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 232.89, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 131.44 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 128 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 197.58, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 119.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6548, "minimum": 5310, "maximum": 31074.776, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10032.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6583.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10744.86, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 7619.19 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6548.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7754.59 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6519.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10136.34 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8512.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6548.28, "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": 6548.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11865.48, "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": 9206.88, "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": 9560.49, "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": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8512.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8185.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6841.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6548.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6548.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10477.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8512.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9822.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6548.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6133.03 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6454.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10343.2 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CCMCC", "code_information": [ { "code": "017", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 51131, "minimum": 48085, "maximum": 100852.43, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90061.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 51383.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 100852.43, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 50148.88 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 51131.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 62574.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 50879.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 90990.16 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 66470.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 51131.53, "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": 51131.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 92650.33, "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": 71890.93, "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": 74652.03, "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": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 66470.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 63914.41, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53398.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 51131.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 51131.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 81810.45, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 66470.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 76697.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 51131.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 78867.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 50375.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 92847.1 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "ANTERIOR COLPORRHAPHY, REPAIR CYSTOCELE", "code_information": [ { "code": "57240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15531.3, "discounted_cash": 6402, "minimum": 617.8, "maximum": 15531.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.18, "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": 617.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $4743", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 4743, "10th_percentile": 4743, "90th_percentile": 4743, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 648.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7169.13, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4200.45 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "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": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8963.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "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": 6402.45, "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": 9001.84, "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": 9347.58, "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": 661.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 15531.25, "discounted_cash": 6402, "minimum": 617.8, "maximum": 15531.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.18, "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": 617.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $4743", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 4743, "10th_percentile": 4743, "90th_percentile": 4743, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 648.69 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7169.13, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4200.45 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "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": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8963.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "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": 6402.45, "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": 9001.84, "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": 9347.58, "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": 661.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ATHEROSCLEROSIS WITH MCC", "code_information": [ { "code": "302", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11451, "minimum": 8260, "maximum": 20750.0999, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17357.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11510.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18304.3, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 12429.53 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11451.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13783.64 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11397.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17536.51 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14886.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11451.49, "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": 11451.49, "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": 20750.1, "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": 16100.79, "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": 16719.18, "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": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14886.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14314.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11962.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11451.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11451.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18322.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14886.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17177.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11451.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15200.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11285, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17894.4 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC", "code_information": [ { "code": "268", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 64673, "minimum": 17700, "maximum": 117189.1249, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 64673.91, "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": 64673.91, "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": 117189.12, "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": 90931.52, "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": 94423.91, "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": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 84076.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 80842.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 67539.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 64673.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 64673.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 103478.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 84076.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 97010.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 64673.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17762.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 102564.2 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99487.27 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 64990.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 111917.3, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 76480.6 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 64673.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 79226.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 64353.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 100512.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 84076.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 63716.6, "additional_payer_notes": "100.00% 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": 20295, "minimum": 10030, "maximum": 38041.852, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30549.28 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20397.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31978.24, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 20617.04 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20295.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24658.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20197.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30864.22 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 26384.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20295.82, "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": 20295.82, "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": 36776.03, "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": 28535.92, "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": 29631.9, "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": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26384.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25369.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21197.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20295.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20295.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32473.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 26384.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 30443.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20295.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37643.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19997.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31494.1 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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": 35252, "minimum": 15930, "maximum": 63878.0192, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53476.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35427.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59623.26, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 38435.37 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 35252.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 43049.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 35079.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 54028.18 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 45828.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 35252.77, "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": 35252.77, "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": 63878.02, "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": 49565.39, "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": 51469.04, "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": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 45828.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 44065.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 36816.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 35252.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35252.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 56404.43, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 45828.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 52879.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35252.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38791.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 34732.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55130.8 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "APPENDIX PROCEDURES WITH MCC", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22677, "minimum": 15045, "maximum": 47227.428, "payers_information": [ { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 29480.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 34015.74, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22677.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34237.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38114.7 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36971.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22790.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36680.44, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 22677.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 27586.85 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22567.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 37352.41 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 29480.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22677.16, "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": 22677.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41091.01, "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": 31884.09, "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": 33108.65, "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": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 29480.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28346.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23684.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22677.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22677.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22343.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36283.46, "additional_payer_notes": "160.00% of Medicare 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "APPENDIX PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10965, "minimum": 5605, "maximum": 22573.484, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16768.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11022.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18173.68, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10965.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13185.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10914.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16941.06 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14254.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10965.29, "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": 10965.29, "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": 19869.11, "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": 15417.2, "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": 16009.32, "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": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14254.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13706.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11454.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10965.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10965.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17544.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14254.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16447.94, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10965.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19802.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10806, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17286.8 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC", "code_information": [ { "code": "095", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24403, "minimum": 16225, "maximum": 45255.428, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35768.65 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24525.59, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38927.05, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 27142.46 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 24403.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 29709.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24285.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36137.4 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 31724.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24403.69, "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": 24403.69, "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": 44219.49, "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": 34311.59, "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": 35629.39, "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": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 31724.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30504.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25487.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24403.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24403.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39045.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 31724.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 36605.54, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24403.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29983.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36874.9 } ] } ] }, { "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": "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 Shield 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" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 4", "code_information": [ { "code": "7584", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22778.37, "maximum": 24372.86, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 WITH CC", "code_information": [ { "code": "519", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18979, "minimum": 9440, "maximum": 34391.0533, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34391.05, "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": 26685.33, "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": 27710.23, "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": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 24673.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23724.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19823.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18979.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18979.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30367.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 24673.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 28469.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18979.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26233.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30332.7 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29422.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19075.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32141.51, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 21522.5 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18979.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 23040.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18888.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29726.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24673.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 18701.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18979.61, "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": 18979.61, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITH MCC", "code_information": [ { "code": "725", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11204, "minimum": 11041.3, "maximum": 20301.956, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18839.24 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11262.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20260.28, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 14155.89 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11204.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13479.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11151.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19033.46 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14565.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11204.17, "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": 11204.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20301.96, "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": 15753.06, "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": 16358.09, "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": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14565.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14005.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11703.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11204.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11204.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17926.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14565.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16806.26, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11204.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16498 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11041.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19421.9 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "AUTOLOGOUS BONE MARROW TRANSPLANT WITH CCMCC", "code_information": [ { "code": "016", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 55791, "minimum": 48085, "maximum": 101093.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90061.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 56065.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 100852.43, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 77637.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 55791.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 68304.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 55515.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 90990.16 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 72528.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 55791.17, "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": 55791.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 101093.6, "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": 78442.39, "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": 81455.11, "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": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 72528.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 69738.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 58263.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 55791.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 55791.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 89265.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 72528.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 83686.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 55791.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 59127.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 54965.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 92847.1 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CCMCC", "code_information": [ { "code": "096", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24403, "minimum": 16225, "maximum": 44219.4863, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35768.65 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24525.59, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35588.16, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 25507.44 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 24403.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 29709.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24285.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36137.4 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 31724.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24403.69, "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": 24403.69, "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": 44219.49, "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": 34311.59, "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": 35629.39, "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": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 31724.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30504.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25487.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24403.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24403.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39045.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 31724.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 36605.54, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24403.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22927.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 24044.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36874.9 } ] } ] }, { "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": 51981, "minimum": 6500, "maximum": 111326.26, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91565.67 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 52236.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 111326.26, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 60651.35 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 51981.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 63619.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 51724.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 92509.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 67575.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 51981.2, "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": 51981.2, "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": 94189.93, "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": 73085.57, "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": 75892.55, "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": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 67575.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 64976.5, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54285.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 51981.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 51981.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 83169.92, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 67575.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 77971.8, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 51981.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 80184.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 51212.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 94397.6 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "410", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15115, "minimum": 9735, "maximum": 31309.444, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23144.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15192.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25555.16, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 18718.16 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15115.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18288.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15043.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23382.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 19649.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15115.31, "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": 15115.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27388.94, "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": 21252.13, "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": 22068.35, "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": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 19649.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18894.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15787.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15115.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15115.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24184.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19649.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 22672.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15115.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24401.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14894.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23859.8 } ] } ] }, { "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": 25160, "minimum": 6500, "maximum": 52455.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42730.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25286.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46471.79, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 35366.05 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 25160.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 30640.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 25038.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 43171.25 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 32708.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 25160.62, "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": 25160.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45591.04, "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": 35375.83, "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": 36734.51, "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": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 32708.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31450.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26277.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25160.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25160.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40256.99, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 32708.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 37740.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25160.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27973 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 24790.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44052.3 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "479", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17655, "minimum": 9735, "maximum": 36657.508, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26496.71 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17745.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30433.69, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 20094.96 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17655.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21412.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17571.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26769.88 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 22952.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17655.92, "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": 17655.92, "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": 31992.53, "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": 24824.22, "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": 25777.64, "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": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 22952.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22069.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18441.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17655.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17655.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28249.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22952.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26483.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17655.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19715.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17397.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27316.2 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "478", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23279, "minimum": 15340, "maximum": 48495.424, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34894.3 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23396.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38918.88, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 26127.62 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 23279.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 28327.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23166.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 35254.03 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 30263.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23279.53, "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": 23279.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42182.51, "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": 32731.02, "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": 33988.11, "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": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 30263.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29099.41, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24313.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23279.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23279.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37247.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 30263.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 34919.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23279.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23463.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22937.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35973.5 } ] } ] }, { "description": "Bone Biopsy Open Superficial", "code_information": [ { "code": "20240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12000, "discounted_cash": 3717, "minimum": 181.57, "maximum": 12000, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 181.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 190.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 194.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 1", "code_information": [ { "code": "1961", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3610.7, "maximum": 3863.45, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "BIOPSYREMOVAL LYMPH NODES", "code_information": [ { "code": "38525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6591.43, "discounted_cash": 5011, "minimum": 212, "maximum": 6591.43, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5061.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6591.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6591.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6591.43, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6591.43, "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": 226.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6264.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5311.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4760.66, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6591.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.44, "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": 212 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5111.44, "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": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 222.6 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5611.3, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2945.57 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6591.43, "additional_payer_notes": "150.00% of Medicare Rates" } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITH MCC", "code_information": [ { "code": "553", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12385, "minimum": 12095, "maximum": 22442.4898, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19486.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12449.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22066.06, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 14495.3 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12385.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14932.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12327.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19687.71 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 16101.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12385.48, "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": 12385.48, "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": 22442.49, "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": 17413.98, "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": 18082.8, "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": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16101.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15481.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12937.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12385.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12385.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19816.77, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16101.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 18578.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12385.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17065.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12205.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20089.5 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC", "code_information": [ { "code": "094", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33211, "minimum": 23305, "maximum": 71224.696, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54442.22 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 33376.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59148.15, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 40422.2 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 33211.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 40539.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33048.92, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 55003.48 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 43174.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 33211.48, "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": 33211.48, "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": 60179.2, "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": 46695.34, "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": 48488.76, "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": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 43174.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 41514.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34685, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33211.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33211.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53138.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 43174.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 49817.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33211.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38844.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 32721.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56126 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC", "code_information": [ { "code": "277", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43507, "minimum": 9735, "maximum": 109765.464, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 70126.55 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 56560.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 43507.85, "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": 43507.85, "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": 78836.22, "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": 61172.04, "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": 63521.46, "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": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 56560.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 54384.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45437.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 43507.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43507.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 69612.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 56560.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 65261.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43507.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 63067.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71557.7 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69410.97 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 43722.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78082.67, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42865.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 43507.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 53200.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 43293.75, "additional_payer_notes": "101.00% of Medicare Rates" } ] } ] }, { "description": "BEHAVIORAL AND DEVELOPMENTAL DISORDERS", "code_information": [ { "code": "886", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19683, "minimum": 13570, "maximum": 35665.8678, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26805.56 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27457.27, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15172.99 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19683.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 23905.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19588.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27081.91 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 25588.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19683.15, "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": 19683.15, "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": 35665.87, "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": 27674.51, "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": 28737.4, "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": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 25588.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24603.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20557.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19683.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19683.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31493.04, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25588.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 29524.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19683.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14452 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19394.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27634.6 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 3", "code_information": [ { "code": "1323", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7546.85, "maximum": 8075.13, "payers_information": [ { "payer_name": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "585", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18313, "minimum": 6490, "maximum": 38164.116, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29619.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18406, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27494.82, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 19138.75 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18313.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22221.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18225.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29925.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23807.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18313.55, "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": 18313.55, "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": 33184.15, "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": 25748.85, "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": 26737.78, "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": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23807.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22891.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19127.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18313.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18313.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29301.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23807.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 27470.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18313.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35606.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18045.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30535.8 } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITHOUT CCMCC", "code_information": [ { "code": "203", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6518, "minimum": 5565.63, "maximum": 18558.492, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10393.94 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6553.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11345.69, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 7823.29 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6518.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7717.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6489.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10501.09 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8473.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6518.3, "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": 6518.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11811.16, "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": 9164.73, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9516.72, "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": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8473.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8147.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6810.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6518.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6518.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10429.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8473.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9777.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6518.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5565.63 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6425.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10715.4 } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "258", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29676, "minimum": 4200, "maximum": 53774.5972, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41860.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 29824.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44223.55, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 34489.9 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 29676.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 36193.85 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 29532, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 42292.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 38580.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 29676.93, "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": 29676.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 53774.6, "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": 41725.76, "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": 43328.32, "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": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 38580.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 37096.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30993.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 29676.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29676.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 47483.09, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 38580.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 44515.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29676.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 36658.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 29239.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43155.5 } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7005, "minimum": 4586.23, "maximum": 29242.788, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11107.18 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7043.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11933.47, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8622.76 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7005.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8316.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6974, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11221.69 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9107.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7005.44, "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": 7005.44, "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": 12693.86, "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": 9849.65, "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": 10227.94, "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": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9107.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8756.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7319.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7005.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7005.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11208.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9107.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10508.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4586.23 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6904.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11450.7 } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITH CCMCC", "code_information": [ { "code": "202", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9339, "minimum": 8555, "maximum": 36107.32, "payers_information": [ { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9339.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11187.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9296.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14572.8 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12141.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9339.94, "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": 9339.94, "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": 16923.97, "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": 13131.96, "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": 13636.31, "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": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12141.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11674.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9757.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9339.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9339.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14943.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12141.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14009.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9339.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8610.96 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14870.2 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14424.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9388.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15633.19, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9204.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 10689.65 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC", "code_information": [ { "code": "261", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17951, "minimum": 4200, "maximum": 32655.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28314.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18042.58, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30724.32, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 21971.29 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17951.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21776.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17865.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28606 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23337.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17951.94, "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": 17951.94, "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": 32528.92, "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": 25240.43, "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": 26209.83, "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": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23337.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22439.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18750.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17951.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17951.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28723.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23337.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26927.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17951.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32655.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17688.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29189.8 } ] } ] }, { "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": 20638, "minimum": 13570, "maximum": 42936.356, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31281.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20742.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31957.01, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 26992.49 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20638.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 25080.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20539.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31604.41 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 26830.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20638.69, "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": 20638.69, "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": 37397.31, "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": 29018, "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": 30132.49, "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": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26830.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25798.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21555.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20638.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20638.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33021.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 26830.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 30958.04, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20638.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31892.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20335.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32249.4 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "260", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30713, "minimum": 4200, "maximum": 69550.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50823.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 30866.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54127.57, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 41716.69 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 30713.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 37469 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 30563.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 51347.88 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 39928.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 30713.97, "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": 30713.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 55653.71, "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": 43183.84, "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": 44842.4, "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": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 39928.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 38392.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32076.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 30713.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30713.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 49142.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 39928.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 46070.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30713.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 69550.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 30261.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52395.8 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "477", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32604, "minimum": 25960, "maximum": 68124.712, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51313.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 32766.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55005.96, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 36706.76 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 32604.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 39793.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 32444.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 51842.29 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 42385.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 32604.43, "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": 32604.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 59079.23, "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": 45841.83, "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": 47602.47, "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": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 42385.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 40755.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34051.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 32604.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32604.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 52167.09, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 42385.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 48906.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32604.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 52583.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 32123.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52900.3 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CCMCC", "code_information": [ { "code": "262", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15510, "minimum": 4200, "maximum": 60291.928, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22647.08 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15589.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26862.96, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 18916.62 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15510.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18774.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15436.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22880.55 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20163.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15510.64, "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": 15510.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28105.28, "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": 21807.96, "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": 22645.53, "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": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20163.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19388.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16200.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15510.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15510.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24817.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20163.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23265.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15510.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19832.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15283.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23347.5 } ] } ] }, { "description": "Biopsy of breast open", "code_information": [ { "code": "19101", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13750, "discounted_cash": 5011, "minimum": 295.31, "maximum": 13750, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.44, "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": 295.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5111.44, "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": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 310.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5611.3, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2973.04 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5061.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7015.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7045.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7316.38, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 315.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6264.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5311.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4760.66, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13750, "discounted_cash": 5011, "minimum": 295.31, "maximum": 13750, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5061.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7015.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7045.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7316.38, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 315.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6264.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5311.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6514.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4760.66, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6601.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6403.44, "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": 295.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5111.44, "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": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 310.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5611.3, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2973.04 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 5011.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 7516.83, "additional_payer_notes": "150.00% 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "CARDIAC ARREST, UNEXPLAINED WITHOUT CCMCC", "code_information": [ { "code": "298", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 4505, "minimum": 3245, "maximum": 14192.484, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6590.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 4530.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7179.02, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 5674.08 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 4505.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 5242.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 4486.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 6658.51 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 5856.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 4505.12, "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": 4505.12, "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": 8163.28, "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": 6334.2, "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": 6577.48, "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": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 5856.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 5631.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 4708.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 4505.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 4505.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7208.19, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 5856.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 6757.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 4505.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5771.64 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 4441.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6794.4 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "216", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 91887, "minimum": 31565, "maximum": 166499.2621, "payers_information": [ { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 147019.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 119453.11, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 137830.52, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 91887.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 135108 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 148457.8 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 144004.07 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 92335.91, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 158459.3, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 113238.1 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 91887.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 112688.07 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 91430.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 145488.64 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 119453.11, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 91887.01, "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": 91887.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 166499.26, "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": 129193.14, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 134155.03, "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": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 119453.11, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 114858.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 95956.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 91887.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 91887.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 90525.4, "additional_payer_notes": "100.00% 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC", "code_information": [ { "code": "308", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11520, "minimum": 10030, "maximum": 20875.7077, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17993.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11580.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19628.43, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 13392.51 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11520.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13868.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11466.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18178.71 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14977.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11520.81, "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": 11520.81, "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": 20875.71, "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": 16198.26, "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": 16820.38, "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": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14977.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14401.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12034.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11520.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11520.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18433.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14977.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17281.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11520.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11290.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11353.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18549.7 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC", "code_information": [ { "code": "306", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15003, "minimum": 11505, "maximum": 27186.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22342.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15080.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25091.47, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15949.9 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15003.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18151.64 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14932.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22573.03 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 19504.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15003.83, "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": 15003.83, "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": 27186.94, "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": 21095.38, "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": 21905.59, "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": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 19504.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18754.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15671.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15003.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15003.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24006.13, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19504.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 22505.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15003.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19565.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14784.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23033.7 } ] } ] }, { "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": 47458, "minimum": 9145, "maximum": 97562.728, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68526.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 47691.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75898.11, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 51826.75 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 47458.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 58058.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 47224.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 69232.69 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 61695.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 47458.33, "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": 47458.33, "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": 85994.49, "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": 66726.41, "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": 69289.16, "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": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 61695.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 59322.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 49562.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 47458.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 47458.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 75933.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 61695.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 71187.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 47458.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 51364.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 46756.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70645.6 } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH MCC", "code_information": [ { "code": "276", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 56511, "minimum": 18290, "maximum": 102398.9648, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 92426.64 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 56789.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 101394.49, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 56511.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 69190.03 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 56232.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 93379.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 73465.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 56511.57, "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": 56511.57, "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": 102398.96, "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": 79455.27, "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": 82506.89, "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": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 73465.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 70639.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 59016.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 56511.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 56511.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 90418.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 73465.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 84767.36, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 56511.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 44349.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 55675.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 95285.2 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC", "code_information": [ { "code": "217", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 61839, "minimum": 15340, "maximum": 129664.916, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 96358.35 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 62142.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 103926.82, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 75003.44 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 61839.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 75740.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 61533.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 97351.73 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 80390.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 61839.15, "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": 61839.15, "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": 112052.54, "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": 86945.84, "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": 90285.16, "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": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 80390.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 77298.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 64579.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 61839.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 61839.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 98942.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 80390.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 92758.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 61839.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 61825.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99338.5 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "036", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18441, "minimum": 3540, "maximum": 38312.016, "payers_information": [ { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29507.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23974.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 27662.84, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18441.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26494.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28197.6 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27351.67 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18534.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29522.64, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 19744.28 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18441.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22379.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18353.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27633.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23974.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18441.89, "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": 18441.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33416.7, "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": 25929.3, "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": 26925.16, "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": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23974.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23052.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19261.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18441.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18441.89, "additional_payer_notes": "100.00% 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": 50199, "minimum": 16520, "maximum": 99392.744, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 79032.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 50446.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85629.05, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 59829.33 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 50199.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 61428.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 49951.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 79846.87 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 65259.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 50199.41, "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": 50199.41, "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": 90961.33, "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": 70580.37, "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": 73291.14, "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": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 65259.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 62749.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52424.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 50199.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 50199.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 80319.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 65259.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 75299.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 50199.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 61701.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 49457.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81476.4 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "219", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 72172, "minimum": 25075, "maximum": 130775.7546, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 115451.24 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 72525.47, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 125901.45, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 88404.97 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 72172.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 88446.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 71814.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 116641.46 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 93823.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 72172.05, "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": 72172.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 130775.75, "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": 101473.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 105371.19, "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": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 93823.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 90215.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 75369.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 72172.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 72172.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 115475.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 93823.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 108258.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 72172.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 89545.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 71103.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 119021.9 } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 1", "code_information": [ { "code": "5401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5389.76, "maximum": 5767.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "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": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5767.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "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": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1621", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38042.75, "maximum": 40705.74, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "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": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40705.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "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": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH MCC", "code_information": [ { "code": "783", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23241, "minimum": 7540, "maximum": 30213.456, "payers_information": [ { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23241.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23241.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17134.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28336.1 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27486.02 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23357.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28928.34, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 20557.28 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 23241.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23128.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27769.38 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 30213.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23241.12, "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": 23241.12, "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": 13628, "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": 10275, "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": 10275, "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": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 30213.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29051.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24273.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23241.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22899.4, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH CC", "code_information": [ { "code": "297", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6181, "minimum": 3835, "maximum": 21051.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10510.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6214.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11895.92, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8152.55 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6181.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7303.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6153.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10618.69 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8035.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6181.05, "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": 6181.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11200.06, "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": 8690.56, "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": 9024.33, "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": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8035.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 7726.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6458.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6181.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6181.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9889.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8035.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9271.58, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6181.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9204.25 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6092.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10835.4 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "785", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9214, "minimum": 7540, "maximum": 14144.16, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13033.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9262.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14144.16, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8226.97 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9214.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9171.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13167.87 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11978.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9214.41, "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": 9214.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11978.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11518.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9625.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9214.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9214.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9214.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8969.99 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9081.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13436.6 } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH MCC", "code_information": [ { "code": "296", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14873, "minimum": 5900, "maximum": 32196.844, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24446.52 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14949.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26175.59, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 17707.83 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14873.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 17991.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14802.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24698.55 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 19335.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14873.62, "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": 14873.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26951, "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": 20912.31, "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": 21715.49, "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": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 19335.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18592.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15535.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14873.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14873.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23797.79, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19335.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 22310.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14873.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27138.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14656.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25202.6 } ] } ] }, { "description": "Care Of Miscarriage", "code_information": [ { "code": "59820", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8051.33, "discounted_cash": 4143, "minimum": 241.91, "maximum": 8051.33, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 258.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3935.93, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.11, "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": 241.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "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": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $2454", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 2454, "10th_percentile": 2454, "90th_percentile": 2454, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.01 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4639.21, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2406.49 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 2", "code_information": [ { "code": "5392", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6779.76, "maximum": 7254.34, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "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": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7254.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "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": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "CELLULITIS WITHOUT MCC", "code_information": [ { "code": "603", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8400, "minimum": 6723.96, "maximum": 29029.812, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13142.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8444.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14444.58, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9511.31 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8400.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10031.9 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8361.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13277.92 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10920.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8400.33, "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": 8400.33, "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": 15221.4, "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": 11810.86, "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": 12264.48, "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": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10920.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10500.41, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8775.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8400.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8400.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13440.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10920.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12600.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8400.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6723.96 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8279.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13548.9 } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH MCC", "code_information": [ { "code": "034", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 36502, "minimum": 13865, "maximum": 76330.204, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58023.27 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 36682.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63698.51, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 42326.72 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 36502.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 44586.59 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 36323.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 58621.44 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 47453.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 36502.46, "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": 36502.46, "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": 66142.46, "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": 51322.46, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 53293.59, "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": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 47453.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45628.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38121.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 36502.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36502.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 58403.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 47453.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 54753.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36502.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50812.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 35963.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59817.8 } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 2", "code_information": [ { "code": "6952", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8459.6, "maximum": 9051.77, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "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": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9051.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "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": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC", "code_information": [ { "code": "309", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7133, "minimum": 6249.57, "maximum": 17187.952, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11031.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7172.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12158.78, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8528.04 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7133.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8474.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7101.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11144.85 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9273.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7133.78, "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": 7133.78, "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": 12926.41, "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": 10030.09, "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": 10415.32, "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": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9273.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8917.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7453.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7133.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7133.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11414.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9273.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10700.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7133.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6249.57 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7031.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11372.3 } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 4", "code_information": [ { "code": "5404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21052.9, "maximum": 22526.6, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "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": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22526.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "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": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 3", "code_information": [ { "code": "6953", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16628.73, "maximum": 17792.74, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "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": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17792.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "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": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "310", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5544, "minimum": 5309.02, "maximum": 14198.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8348.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 5575.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9028.88, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 6306.67 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 5544.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 6520.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 5520.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 8434.37 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7208.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 5544.96, "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": 5544.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10047.47, "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": 7796.21, "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": 8095.64, "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": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 7208.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 6931.2, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5794.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 5544.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5544.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 8871.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 7208.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8317.44, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5544.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5309.02 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 5466.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8606.5 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 3", "code_information": [ { "code": "5393", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11858.17, "maximum": 12688.24, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "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": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12688.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "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": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC", "code_information": [ { "code": "846", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24528, "minimum": 17700, "maximum": 44445.2434, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38105.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 24650.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39903.41, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 29617.54 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 24528.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 29863.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24409.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 38498.12 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 31886.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24528.28, "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": 24528.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44445.24, "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": 34486.76, "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": 35811.29, "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": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 31886.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30660.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25617.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24528.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24528.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39245.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 31886.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 36792.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24528.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18356.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 24167.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39283.8 } ] } ] }, { "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "CESAREAN SECTION WITHOUT STERILIZATION WITH MCC", "code_information": [ { "code": "786", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15694, "minimum": 7540, "maximum": 28564.24, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24110.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15773.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28564.24, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 16432.51 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15694.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15619.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24359.37 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20402.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15694.26, "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": 15694.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "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": 10275, "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": 10275, "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": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20402.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19617.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16392.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15694.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15694.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15694.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15464.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24856.5 } ] } ] }, { "description": "CHEST PAIN - SOI : 4", "code_information": [ { "code": "2034", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9476.23, "maximum": 10139.57, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "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": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10139.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "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": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC", "code_information": [ { "code": "837", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45248, "minimum": 30680, "maximum": 81990.137, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74712.41 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 45471.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 79088.42, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 67552.26 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 45248.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 55340.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 45025.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 75482.64 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 58822.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 45248.42, "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": 45248.42, "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": 81990.14, "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": 63619.28, "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": 66062.69, "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": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 58822.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 56560.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 47254.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 45248.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45248.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 72397.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 58822.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 67872.63, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45248.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 59892.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 44579.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77023.1 } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC", "code_information": [ { "code": "307", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8796, "minimum": 6490, "maximum": 15939.4392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13822.79 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8842.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15389.91, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9947.69 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8796.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10519.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8756.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13965.29 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11435.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8796.6, "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": 8796.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15939.44, "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": 12368.02, "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": 12843.04, "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": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11435.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10995.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9189.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8796.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8796.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14074.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11435.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13194.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8796.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10433.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8669.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14250.3 } ] } ] }, { "description": "CHEST PAIN", "code_information": [ { "code": "313", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6986, "minimum": 5015, "maximum": 13451.012, "payers_information": [ { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6986.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6986.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11178.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9082.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10480.05, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6986.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7715.13 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10973.9 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10644.68 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7024.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11814.28, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8065.72 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6986.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8293.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6955.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10754.42 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9082.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6986.7, "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": 6986.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12659.9, "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": 9823.3, "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": 10200.58, "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": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9082.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8733.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.49, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC", "code_information": [ { "code": "414", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33616, "minimum": 22420, "maximum": 70254.472, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52280.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 33782.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57556.25, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 38523.33 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 33616.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 41037.59 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33451.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 52819.16 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 43701.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 33616.18, "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": 33616.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 60912.52, "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": 47264.35, "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": 49079.62, "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": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 43701.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 42020.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35107.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33616.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33616.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53785.89, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 43701.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 50424.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33616.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 45782.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 33120.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53897.1 } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC", "code_information": [ { "code": "275", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 67039, "minimum": 24485, "maximum": 121475.266, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 105446.76 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 67367.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 114874.13, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 67039.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 82135.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 66707.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 106533.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 87151.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 67039.33, "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": 67039.33, "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": 121475.27, "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": 94257.3, "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": 97877.42, "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": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 87151.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 83799.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 70009.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 67039.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 67039.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 107262.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 87151.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 100559, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 67039.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 76656.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 66046.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 108708 } ] } ] }, { "description": "CHEST PAIN - SOI : 3", "code_information": [ { "code": "2033", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6017.13, "maximum": 6438.33, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "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": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6438.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "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": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS WITH MCC", "code_information": [ { "code": "602", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13556, "minimum": 13358.7, "maximum": 24564.3418, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21921.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13625.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24286.54, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 16122.42 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13556.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16371.95 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13492.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22147.9 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17623.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13556.48, "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": 13556.48, "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": 24564.34, "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": 19060.41, "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": 19792.46, "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": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17623.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16945.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14160.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13556.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13556.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21690.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17623.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20334.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13556.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14940.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13358.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22599.9 } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH MCC", "code_information": [ { "code": "411", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31187, "minimum": 16815, "maximum": 65141.076, "payers_information": [ { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 40543.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 31187.05, "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": 31187.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56510.93, "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": 43848.99, "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": 45533.09, "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": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 40543.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 38983.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32570.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31187.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31187.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 49899.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 40543.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 46780.58, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31187.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35755.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42092.6 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40829.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 31341.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49640.88, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30727.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 43191.59 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 31187.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 38050.71 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 31034.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 41250.75 } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 3", "code_information": [ { "code": "1773", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18511.47, "maximum": 19807.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "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": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19807.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "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": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES", "code_information": [ { "code": "018", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 404778, "minimum": 36285, "maximum": 851564.816, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 562712.71 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 406743.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 601534.04, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 404778.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 497422.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 402755.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 568513.88 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 526211.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 404778.21, "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": 404778.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 733458.12, "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": 569118.16, "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": 590976.19, "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": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 526211.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 505972.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 422694.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 404778.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 404778.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 647645.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 526211.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 607167.32, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 404778.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 427574 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 398768, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 580116.2 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH MCC", "code_information": [ { "code": "471", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45477, "minimum": 20945, "maximum": 95221.964, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72475.78 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 45701, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80312.95, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 56316.85 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 45477, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 55621.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 45252.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 73222.95 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 59120.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 45477, "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": 45477, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 82404.32, "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": 63940.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 66396.42, "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": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 59120.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 56846.25, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 47493.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 45477, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45477, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 72763.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 59120.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 68215.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45477, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 51856.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 44804.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74717.3 } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 2", "code_information": [ { "code": "2632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11931.43, "maximum": 12766.63, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "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": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12766.63, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "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": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC", "code_information": [ { "code": "259", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19184, "minimum": 4200, "maximum": 64145.216, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26226.67 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19281.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30476.14, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 23483.4 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19184.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 23292.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19092.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26497.04 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24940.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19184.77, "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": 19184.77, "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": 34762.8, "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": 26973.79, "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": 28009.76, "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": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 24940.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23980.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20037.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19184.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19184.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30695.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 24940.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 28777.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19184.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22966.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18903.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27037.8 } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 2", "code_information": [ { "code": "5402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6800.75, "maximum": 7276.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "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": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7276.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "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": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "287", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10266, "minimum": 4200, "maximum": 53366.264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16259.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10319.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17659.38, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 12992.21 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10266.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12326.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10218.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16427.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 13346.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10266.44, "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": 10266.44, "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": 18602.79, "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": 14434.61, "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": 14989, "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": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13346.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12833.05, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10724.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10266.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10266.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16426.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13346.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15399.66, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10266.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14268.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10117.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16762.3 } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 2", "code_information": [ { "code": "2002", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5660.93, "maximum": 6057.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "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": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6057.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "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": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 1", "code_information": [ { "code": "5391", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5511.04, "maximum": 5896.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "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": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5896.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "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": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "434", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6916, "minimum": 6195, "maximum": 14050.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10392.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6953.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10930.99, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 7215.51 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6916.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8207.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6885.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10499.62 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8991.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6916.44, "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": 6916.44, "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": 12532.59, "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": 9724.51, "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": 10098, "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": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8991.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8645.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7226.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6916.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6916.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11066.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8991.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10374.66, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6916.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7825.79 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6817.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10713.9 } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 3", "code_information": [ { "code": "2003", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8622.85, "maximum": 9226.45, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "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": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9226.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "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": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC", "code_information": [ { "code": "415", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19602, "minimum": 13275, "maximum": 40755.324, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19602.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19602.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31364.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25483.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 29403.89, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19602.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26429.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30428.1 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29515.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19701.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32259.06, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 23134.97 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19602.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 23806.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19508.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29819.54 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 25483.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19602.59, "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": 19602.59, "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": 35519.89, "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": 27561.24, "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": 28619.78, "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": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 25483.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24503.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20473.79, "additional_payer_notes": "106.00% of Medicare Rates" } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "788", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9223, "minimum": 7540, "maximum": 13959.66, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13499.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9272.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13959.66, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8685.9 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9223.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9181.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13638.17 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11990.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9223.78, "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": 9223.78, "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": 13628, "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": 10275, "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": 10275, "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": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11990.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11529.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9635.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9223.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9223.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9223.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11695.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9090.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13916.5 } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CCMCC", "code_information": [ { "code": "218", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 61839, "minimum": 6785, "maximum": 151416.076, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88769.55 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 62142.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 93010.53, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 60906.19 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 61839.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 75740.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 61533.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 89684.7 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 80390.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 61839.15, "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": 61839.15, "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": 112052.54, "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": 86945.84, "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": 90285.16, "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": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 80390.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 77298.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 64579.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 61839.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 61839.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 98942.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 80390.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 92758.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 61839.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 77736.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 60924, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91515 } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "416", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13013, "minimum": 8260, "maximum": 26884.276, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20444.79 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13079.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21865.24, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15225.98 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13013.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15703.85 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12951.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20655.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 16917.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13013.13, "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": 13013.13, "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": 23579.79, "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": 18296.46, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18999.17, "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": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16917.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16266.41, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13592.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13013.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13013.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20821.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16917.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 19519.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13013.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26745.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12823.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21077.1 } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 1", "code_information": [ { "code": "6951", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5846.45, "maximum": 6255.7, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "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": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6255.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "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": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 3", "code_information": [ { "code": "6613", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11209.5, "maximum": 11994.17, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "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": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11994.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "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": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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 Shield 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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "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 Healthcare", "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": "CHROMOTUBATION OF OVIDUCT,INC MATERIALS", "code_information": [ { "code": "58350", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6500, "discounted_cash": 6402, "minimum": 82.13, "maximum": 6500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.24 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4200.45 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "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": 6402.45, "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": 6500, "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": 6500, "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": 87.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 6500, "discounted_cash": 6402, "minimum": 82.13, "maximum": 6500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.24 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4200.45 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "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": 6402.45, "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": 6500, "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": 6500, "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": 87.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT", "code_information": [ { "code": "838", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19796, "minimum": 15340, "maximum": 35871.258, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30262.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19896.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32681.93, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 24670.76 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19796.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24044.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19701.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30574.73 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 25735.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19796.5, "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": 19796.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35871.26, "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": 27833.88, "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": 28902.89, "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": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 25735.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24745.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20676.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19796.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19796.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31674.4, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25735.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 29694.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19796.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18303.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19506, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31198.7 } ] } ] }, { "description": "COAGULATION DISORDERS", "code_information": [ { "code": "813", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14530, "minimum": 10620, "maximum": 41938.524, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25470.26, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 17874.72 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 14530.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 17569.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14461.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23335.86 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 18889.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14530.75, "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": 14530.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26329.72, "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": 20430.23, "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": 21214.9, "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": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 18889.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18163.44, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15177.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14530.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14530.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23249.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18889.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 21796.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14530.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14727.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23812.1 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23097.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14604.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 14318.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 71005.5, "maximum": 75975.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 75975.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "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": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 1", "code_information": [ { "code": "4701", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3852.4, "maximum": 4122.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "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": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4122.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "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": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "848", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8198, "minimum": 7965, "maximum": 53431.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12218.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8242.31, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13652.71, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11066.27 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8198.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9784.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8161.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12344.77 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10658.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8198.92, "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": 8198.92, "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": 14856.44, "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": 11527.68, "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": 11970.42, "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": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10658.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10248.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8565.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8198.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8198.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13118.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10658.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12298.38, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8198.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8579.18 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8080.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12596.7 } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 3", "code_information": [ { "code": "7743", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5959.88, "maximum": 6377.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "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": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6377.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "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": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 1", "code_information": [ { "code": "2051", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4035.8, "maximum": 4318.31, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "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": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4318.31, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "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": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 4", "code_information": [ { "code": "4704", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14561.53, "maximum": 15580.84, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "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": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15580.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "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": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEST PAIN - SOI : 1", "code_information": [ { "code": "2031", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4004, "maximum": 4284.28, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4004, "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": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4284.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "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": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Colonoscopy W/Lesion Removal", "code_information": [ { "code": "45385", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8415.4, "discounted_cash": 1531, "minimum": 574.08, "maximum": 8495.31, "payers_information": [ { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 614.27 }, { "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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1991, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan 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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA 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": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1991, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1991, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1454.96, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $1473", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 1473, "10th_percentile": 1473, "90th_percentile": 1473, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 602.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1714.94, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1091.94 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 2297.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% 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 Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH CC", "code_information": [ { "code": "035", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22635, "minimum": 5605, "maximum": 47140.66, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33942.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22749.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37544.14, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 25959.61 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 22635.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 27536.17 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22526.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34292.26 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 29426.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22635.94, "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": 22635.94, "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": 41016.32, "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": 31826.13, "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": 33048.47, "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": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 29426.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28294.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23641.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22635.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22635.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36217.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 29426.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 33953.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22635.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32361.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34992.1 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 3", "code_information": [ { "code": "1403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7406.92, "maximum": 7925.4, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "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": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7925.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "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": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH CC", "code_information": [ { "code": "412", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19937, "minimum": 12980, "maximum": 41461.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31805.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20038.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33733.4, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 26803.05 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19937.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24218.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19841.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32133.51 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 25919.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19937.96, "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": 19937.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36127.58, "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": 28032.77, "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": 29109.42, "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": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 25919.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24922.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20824.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19937.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19937.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31900.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25919.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 29906.94, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19937.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27852.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19645.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32789.3 } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC", "code_information": [ { "code": "453", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 106073.33, "maximum": 144680.87, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 144680.87, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 106073.33 } ] } ] }, { "description": "Carpal Tunnel Surgery", "code_information": [ { "code": "64721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 2499, "minimum": 454.46, "maximum": 9400, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3193.55, "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": 454.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2549.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 477.18 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2798.5, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2201.22 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3748.83, "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": 2524.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3292.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3498.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "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": 2499.22, "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": 3513.9, "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": 3648.86, "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": 486.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3124.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2649.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2374.26, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3292.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 4", "code_information": [ { "code": "1404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12433.91, "maximum": 13304.28, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "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": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13304.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "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": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "413", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15797, "minimum": 8260, "maximum": 32745.06, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24806.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15877.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24647.37, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 18236.67 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15797.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19127.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15721.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25061.93 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20536.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15797.3, "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": 15797.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28624.71, "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": 22211, "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": 23064.06, "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": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20536.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19746.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16500.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15797.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15797.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25275.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20536.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23695.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15797.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21723.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15566.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25573.4 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH CC", "code_information": [ { "code": "381", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10391, "minimum": 9440, "maximum": 21366.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16250.51 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10446.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17518.97, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 12140.87 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10391.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12480.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10343.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16418.04 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 13509.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10391.97, "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": 10391.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18830.25, "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": 14611.11, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15172.28, "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": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13509.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12989.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10855.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10391.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10391.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16627.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13509.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15587.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10391.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11818.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10241.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16753.1 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC", "code_information": [ { "code": "191", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8138, "minimum": 7965, "maximum": 15892.348, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12818.65 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8182.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13861.7, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 10067.21 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8138.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9710.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8101.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12950.8 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10580.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8138.96, "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": 8138.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14747.8, "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": 11443.38, "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": 11882.88, "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": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10580.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10173.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8502.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8138.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8138.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13022.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10580.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12208.44, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8138.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9457.34 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8021.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13215.1 } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 1", "code_information": [ { "code": "2631", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9312.98, "maximum": 9964.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "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": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9964.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "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": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITHOUT CCMCC", "code_information": [ { "code": "921", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6690, "minimum": 6195, "maximum": 34498.168, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10261.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6726.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11393.04, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 7787.21 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6690.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7929.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6660.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10366.93 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8697.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6690.67, "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": 6690.67, "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": 12123.49, "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": 9407.08, "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": 9768.38, "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": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8697.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8363.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6990.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6690.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6690.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10705.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8697.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10036.01, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6690.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7075.93 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6594.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10578.5 } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 3", "code_information": [ { "code": "2633", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16322.36, "maximum": 17464.93, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "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": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17464.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "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": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES", "code_information": [ { "code": "212", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 102110, "minimum": 36875, "maximum": 196352.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 162547.94 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 102608.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 175854.18, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 102110.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 125258.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 101602.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 164223.7 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 132743.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 102110.31, "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": 102110.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 185023.88, "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": 143567.1, "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": 149081.05, "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": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 132743.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 127637.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 106632.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 102110.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 102110.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 163376.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 132743.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 153165.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 102110.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 142345 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 100597, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 167575.2 } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 2", "code_information": [ { "code": "0952", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8045.1, "maximum": 8608.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "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": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8608.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "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": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 2", "code_information": [ { "code": "4702", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4928.4, "maximum": 5273.39, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "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": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5273.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "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": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION WITH CC", "code_information": [ { "code": "089", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10533, "minimum": 7375, "maximum": 20173.56, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15996.85 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10588.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18774.52, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11121.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10533.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12654.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10484.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16161.77 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 13693.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10533.42, "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": 10533.42, "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": 19086.56, "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": 14809.99, "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": 15378.79, "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": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13693.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13166.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11003.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10533.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10533.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16853.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13693.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15800.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10533.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17907 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10380.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16491.6 } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 2", "code_information": [ { "code": "0572", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6917.15, "maximum": 7401.35, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "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": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7401.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Circum 28 Days Or Older", "code_information": [ { "code": "54161", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11883.3, "discounted_cash": 2675, "minimum": 181.57, "maximum": 11883.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 181.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $1473", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 1473, "10th_percentile": 1473, "90th_percentile": 1845.3, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 190.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2995.78, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2750.77 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3745.57, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3761.63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3906.1, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 194.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3344.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2541.64, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 1", "code_information": [ { "code": "3461", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5540.08, "maximum": 5927.89, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "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": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5927.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "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": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 4", "code_information": [ { "code": "7744", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15091.58, "maximum": 16147.99, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "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": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16147.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "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": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "432", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18679, "minimum": 14455, "maximum": 38812.904, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29231.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18774.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31282.7, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 20560.66 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18679.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22671.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18589.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29533.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24283.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18679.84, "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": 18679.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33847.87, "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": 26263.86, "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": 27272.57, "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": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 24283.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23349.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19510.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18679.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18679.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29887.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 24283.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 28019.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18679.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23319.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18405.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30135.8 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 4", "code_information": [ { "code": "3464", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21898.49, "maximum": 23431.38, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "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": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23431.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "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": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COLPOPEXY EXTRAPERITONEAL", "code_information": [ { "code": "57282", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11375, "discounted_cash": 9490, "minimum": 502.23, "maximum": 11375, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9680.57, "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": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 527.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10627.25, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5362.44 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9585.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "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": 9490.75, "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": 11375, "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": 11375, "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": 537.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10060.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9016.21, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 11375, "discounted_cash": 9490, "minimum": 502.23, "maximum": 11375, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9680.57, "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": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 527.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10627.25, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5362.44 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9585.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "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": 9490.75, "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": 11375, "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": 11375, "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": 537.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10060.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9016.21, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 502.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9490.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11375, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Clear Outer Ear Canal", "code_information": [ { "code": "69205", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12711.3, "discounted_cash": 2113, "minimum": 115.35, "maximum": 12711.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 115.35 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.12 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2366.95, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 115.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 123.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 115.35 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 115.35 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 115.35 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 115.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "547", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8075, "minimum": 7080, "maximum": 38077.348, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8075.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12920.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10497.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12112.89, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8075.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9512.67 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11478.4 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11134.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8118.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13442.09, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9134.69 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8075.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9632.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8038.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11248.83 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10497.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8075.26, "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": 8075.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14632.37, "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": 11353.82, "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": 11789.88, "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": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10497.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10094.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8436.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8075.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7958.88, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 2", "code_information": [ { "code": "3832", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5117.1, "maximum": 5475.3, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "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": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5475.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "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": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH MCC", "code_information": [ { "code": "380", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18623, "minimum": 14750, "maximum": 38694.584, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28712.49 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18717.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31813.33, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 21284.58 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18623.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22602.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18534.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29008.49 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24210.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18623.63, "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": 18623.63, "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": 33746.02, "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": 26184.82, "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": 27190.5, "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": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 24210.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23279.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19451.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18623.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18623.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29797.81, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 24210.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 27935.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18623.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17622.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18350.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29600.5 } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 1", "code_information": [ { "code": "0951", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7198.08, "maximum": 7701.95, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "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": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7701.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "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": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 1", "code_information": [ { "code": "3841", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4735.47, "maximum": 5066.95, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "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": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5066.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "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": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH CC", "code_information": [ { "code": "472", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 27840, "minimum": 7375, "maximum": 58097.092, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43229.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 27979.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48253.08, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 34295.95 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 27840.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 33936.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 27705.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 43674.78 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 36193.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 27840.8, "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": 27840.8, "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": 50447.53, "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": 39144.16, "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": 40647.57, "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": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 36193.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 34801, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29076.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 27840.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 27840.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 44545.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 36193.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 41761.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 27840.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32459.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 27430.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44566.1 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITHOUT CCMCC", "code_information": [ { "code": "382", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7741, "minimum": 6979.41, "maximum": 15787.832, "payers_information": [ { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11612.64, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7741.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6979.41 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11526.1 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11180.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7782.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12361.24, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8923.83 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7741.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9222.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7706.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11295.58 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10064.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7741.76, "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": 7741.76, "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": 14028.07, "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": 10884.91, "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": 11302.97, "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": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10064.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9677.2, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8088.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7741.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7741.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12386.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10064.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7630.33, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 4", "code_information": [ { "code": "0954", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19181.45, "maximum": 20524.15, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "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": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20524.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "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": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 4", "code_information": [ { "code": "3844", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15409.61, "maximum": 16488.28, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "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": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16488.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "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": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "473", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23111, "minimum": 4720, "maximum": 48142.436, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35324.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23227.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40174.44, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 28329.82 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 23111.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 28121.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22999.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 35688.17 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 30045.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23111.84, "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": 23111.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41878.65, "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": 32495.25, "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": 33743.29, "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": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 30045.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28889.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24138.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23111.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23111.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36978.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 30045.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 34667.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23111.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27734 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22772.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36416.5 } ] } ] }, { "description": "Conization Of Cervix", "code_information": [ { "code": "57522", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10540.8, "discounted_cash": 4143, "minimum": 321.98, "maximum": 10540.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.11, "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": 321.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "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": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 338.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4639.21, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2406.49 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3935.93, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1653", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 46931.69, "maximum": 50216.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "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": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50216.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "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": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 3", "code_information": [ { "code": "5403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9359.2, "maximum": 10014.34, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "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": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10014.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "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": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cor hlx vlgs rsc prx phlx bs", "code_information": [ { "code": "28292", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5585.93, "discounted_cash": 4187, "minimum": 423.48, "maximum": 5585.93, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 423.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 444.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4689.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3813.04 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5585.93, "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": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5585.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5585.93, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5585.93, "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": 453.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Cmbn Ant Pst Colprhy", "code_information": [ { "code": "57260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26000, "discounted_cash": 6402, "minimum": 872.17, "maximum": 26000, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.18, "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": 872.17 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 915.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7169.13, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4200.45 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "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": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8963.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "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": 6402.45, "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": 9001.84, "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": 9347.58, "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": 933.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC", "code_information": [ { "code": "233", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 71861, "minimum": 33335, "maximum": 130213.8896, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 116628.53 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 72213.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 127344.76, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 87602.12 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 71861.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 88065.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 71505.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 117830.89 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 93420.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 71861.97, "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": 71861.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 130213.89, "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": 101037.93, "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": 104918.48, "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": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 93420.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 89827.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 75045.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 71861.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 71861.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 114979.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 93420.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 107792.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 71861.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 92378 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 70797.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 120235.6 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH CC", "code_information": [ { "code": "784", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10172, "minimum": 7540, "maximum": 16720.57, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16159.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16720.57, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 10017.6 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10172.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10125.45, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16326.02 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 13224.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10172.76, "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": 10172.76, "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": 13628, "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": 10275, "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": 10275, "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": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13224.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12715.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10626.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10172.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10172.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10172.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10811.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10025.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16659.2 } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1654", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 63659, "maximum": 68115.13, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 63659, "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": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 68115.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "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": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cmplx rpr enel 1.1-2.5 cm", "code_information": [ { "code": "13151", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5850, "discounted_cash": 945, "minimum": 234.44, "maximum": 5850, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 964.83, "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": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 246.16 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1059.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 579.26 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1324.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1329.95, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1381.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1229.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1182.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1002.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1229.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1229.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 898.61, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 5850, "discounted_cash": 945, "minimum": 234.44, "maximum": 5850, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 964.83, "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": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 246.16 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1059.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 579.26 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1324.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1329.95, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1381.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1229.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1182.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1002.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1229.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1229.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 898.61, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CORONARY BYPASS WITH PTCA WITHOUT MCC", "code_information": [ { "code": "232", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 57036, "minimum": 22420, "maximum": 150763.344, "payers_information": [ { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 85554.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57036.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 79820 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 93966.9 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91147.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 57316.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 97123.32, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 67503.77 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 57036.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 69835.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 56754.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 92087.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 74147.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 57036.18, "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": 57036.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 103349.56, "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": 80192.87, "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": 83272.82, "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": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 74147.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 71295.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 59563.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 57036.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57036.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56192.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 91257.89, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 74147.03, "additional_payer_notes": "130.00% of Medicare Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 4", "code_information": [ { "code": "5394", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24337.19, "maximum": 26040.79, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "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": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26040.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "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": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITH PTCA WITH MCC", "code_information": [ { "code": "231", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 79213, "minimum": 31860, "maximum": 143534.0285, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 126439.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 79600.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 132497.59, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 92592.87 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 79213.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 97104.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 78820.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 127742.61 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 102976.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 79213.04, "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": 79213.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 143534.03, "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": 111373.53, "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": 115651.04, "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": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 102976.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 99016.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 82722.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 79213.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 79213.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 126740.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 102976.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 118819.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 79213.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 69738.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 78039.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 130349.6 } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 1", "code_information": [ { "code": "6611", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6078.61, "maximum": 6504.11, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "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": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6504.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "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": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1664", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 55046.75, "maximum": 58900.02, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "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": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58900.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "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": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITH CC", "code_information": [ { "code": "787", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10703, "minimum": 7540, "maximum": 17161.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15843.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10759.47, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17161.4, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 10020.98 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10703.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8000 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10653.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16006.44 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 13915.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10703.92, "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": 10703.92, "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": 13628, "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": 10275, "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": 10275, "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": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13915.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13379.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11181.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10703.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10703.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8000, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10703.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16002.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16333.1 } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1661", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29768.67, "maximum": 31852.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "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": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31852.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "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": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 4", "code_information": [ { "code": "6614", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19298.06, "maximum": 20648.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "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": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20648.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "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": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR", "code_information": [ { "code": "023", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 53923, "minimum": 21535, "maximum": 113001.516, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 53923.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 53923.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 86277.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 70100.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 80884.79, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 53923.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 74508.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87758.6 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85125.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 54188.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 92555, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 63338.42 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 53923.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 66007.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 53656.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 86003.43 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 70100.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 53923.19, "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": 53923.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 97708.82, "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": 75816.01, "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": 78727.86, "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": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 70100.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 67403.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 53125.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56313.24, "additional_payer_notes": "106.00% of Medicare Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 4", "code_information": [ { "code": "6954", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39025.46, "maximum": 41757.24, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "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": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41757.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "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": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "026", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29368, "minimum": 8850, "maximum": 61313.424, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45637.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 29514.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48215.53, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 34344.44 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 29368.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 35814.87 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 29225.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 46107.82 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 38179.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 29368.73, "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": 29368.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 53216.14, "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": 41292.43, "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": 42878.35, "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": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 38179.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 36710.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30672.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 29368.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29368.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 46989.97, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 38179.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 44053.1, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29368.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33433.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 28936, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47048.8 } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 1", "code_information": [ { "code": "7741", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2749.9, "maximum": 2942.39, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "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": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2942.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "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": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "839", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13768, "minimum": 11505, "maximum": 63792.228, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20447.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13838.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21275.83, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 14390.43 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16632.28 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13702.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20658.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17898.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13768.2, "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": 13768.2, "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": 24947.98, "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": 19358.09, "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": 20101.57, "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": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17898.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17210.25, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14381.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22029.12, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17898.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20652.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12107.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21080.1 } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 3", "code_information": [ { "code": "9103", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33747.22, "maximum": 36109.53, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "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": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36109.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "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": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 2", "code_information": [ { "code": "7742", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3481.37, "maximum": 3725.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "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": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3725.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "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": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC", "code_information": [ { "code": "847", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12496, "minimum": 10638, "maximum": 22644.4915, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12496.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12496.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19995.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16246.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 18745.44, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12496.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10638 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19546.5 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18960.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12561.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19798.23, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 14838.09 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12496.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15069.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12438.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19155.57 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 16246.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12496.96, "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": 12496.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22644.49, "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": 17570.73, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18245.56, "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": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16246.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15621.2, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12314.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13053.79, "additional_payer_notes": "106.00% of Medicare Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 4", "code_information": [ { "code": "9104", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 56988.86, "maximum": 60978.08, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "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": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60978.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "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": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 3", "code_information": [ { "code": "1313", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17564.8, "maximum": 18794.34, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "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": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18794.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "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": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEST PAIN - SOI : 2", "code_information": [ { "code": "2032", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4785.29, "maximum": 5120.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "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": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5120.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "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": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 1", "code_information": [ { "code": "0451", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6539.76, "maximum": 6997.54, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "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": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6997.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "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": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC", "code_information": [ { "code": "454", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 69065.5, "maximum": 99861.37, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99861.37, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 69065.5 } ] } ] }, { "description": "CYSTOSCOPY", "code_information": [ { "code": "52000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27500, "discounted_cash": 892, "minimum": 124.43, "maximum": 27500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1140.39, "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": 124.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 910.3, "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": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 999.32, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 789.43 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1338.68, "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": 901.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1175.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1249.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "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": 892.45, "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": 1254.78, "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": 1302.98, "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": 133.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1115.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 946, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 847.83, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1175.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 27500, "discounted_cash": 892, "minimum": 124.43, "maximum": 27500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1140.39, "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": 124.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 910.3, "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": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 999.32, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 789.43 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1338.68, "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": 901.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1175.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1249.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "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": 892.45, "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": 1254.78, "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": 1302.98, "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": 133.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1115.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 946, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 847.83, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 892.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1175.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 4", "code_information": [ { "code": "2634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27036.79, "maximum": 28929.37, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "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": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28929.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "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": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 4", "code_information": [ { "code": "0454", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16939.34, "maximum": 18125.09, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "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": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18125.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "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": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "455", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54274.77, "maximum": 75196.04, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75196.04, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 54274.77 } ] } ] }, { "description": "Cystoscopy And Treatment - 52235 - OR36052235", "code_information": [ { "code": "52235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13000, "discounted_cash": 4511, "minimum": 640.83, "maximum": 13000, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 672.87 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 685.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 640.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 3", "code_information": [ { "code": "4703", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8182.91, "maximum": 8755.71, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "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": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8755.71, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "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": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH CC", "code_information": [ { "code": "920", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9631, "minimum": 8555, "maximum": 17451.8975, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15158.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9681.63, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16878.94, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11360.57 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11545.49 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9586.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15314.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12520.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9631.29, "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": 9631.29, "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": 17451.9, "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": 13541.59, "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": 14061.68, "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": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12520.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12039.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10061.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15410.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12520.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14446.94, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9631.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9722.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9491.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15627.1 } ] } ] }, { "description": "Cystoscopy And Treatment - 52332 - OR36052332", "code_information": [ { "code": "52332", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14533.3, "discounted_cash": 4511, "minimum": 789.82, "maximum": 14533.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 829.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 845.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 1", "code_information": [ { "code": "1401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4604.01, "maximum": 4926.29, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "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": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4926.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "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": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTO WURETER STRICTURE TX", "code_information": [ { "code": "52341", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7175, "discounted_cash": 4511, "minimum": 281.09, "maximum": 7175, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 300.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 7175, "discounted_cash": 4511, "minimum": 281.09, "maximum": 7175, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 300.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH MCC", "code_information": [ { "code": "919", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17392, "minimum": 12980, "maximum": 31515.518, "payers_information": [ { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 22610.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21740.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18166.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17392.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17392.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27828.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22610.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26089.01, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17392.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16785.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28051.5 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27209.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17480.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29792.04, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 20582.08 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17392.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21088.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17309.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27490.47 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 22610.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17392.67, "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": 17392.67, "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": 31515.52, "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": 24454.09, "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": 25393.3, "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": 17137.9, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Dbrdmt Subq Tis 1St 20Sqcm/<", "code_information": [ { "code": "11042", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5449, "discounted_cash": 520, "minimum": 148.99, "maximum": 5449, "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": 148.99 }, { "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 156.44 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 582.58, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 321.63 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "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 Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 780.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 525.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 685.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% 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 Excel Inc", "plan_name": "Health Excel Inc Medicare", "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 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": 159.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 676.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 650.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan 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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA 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": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 676.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 676.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 494.27, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.99 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 685.39, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 2", "code_information": [ { "code": "1402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5528.42, "maximum": 5915.41, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "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": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5915.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "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": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cystoscopy And Treatment - 52234 - OR36052234", "code_information": [ { "code": "52234", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13937.5, "discounted_cash": 4511, "minimum": 363.13, "maximum": 13937.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $2127", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 2127, "10th_percentile": 2127, "90th_percentile": 2127, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 381.29 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 388.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONCUSSION WITHOUT CCMCC", "code_information": [ { "code": "090", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7953, "minimum": 5900, "maximum": 15703.036, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11612.08, "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": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10339.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9941.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8309.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7953.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7953.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12725.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10339.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11930.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7953.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14669.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13187.4 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12791.78 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7995.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15262.56, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9565.43 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7953.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9482.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7917.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12923.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10339.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7838.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7953.48, "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": 7953.48, "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": 14411.71, "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": 11182.59, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "DEEP VEIN THROMBOPHLEBITIS WITHOUT CCMCC", "code_information": [ { "code": "295", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6506.25, "maximum": 13014.32, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11784.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13014.32, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 6506.25 }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11906.12 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10320.2 }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12149.1 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC", "code_information": [ { "code": "190", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10618, "minimum": 10030, "maximum": 25919.968, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16756.27 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10673.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17992.45, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 12899.74 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10618.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12759.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10569.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16929.01 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 13804.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10618.67, "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": 10618.67, "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": 19241.03, "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": 14929.85, "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": 15503.26, "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": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13804.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13273.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11092.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10618.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10618.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16989.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13804.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15928.01, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10618.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10629.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10464.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17274.5 } ] } ] }, { "description": "Cystoscopy And Treatment - 52281 - OR36052281", "code_information": [ { "code": "52281", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10850, "discounted_cash": 2675, "minimum": 181.57, "maximum": 10850, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 181.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 190.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2995.78, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2038.82 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3745.57, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3761.63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3906.1, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 194.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3344.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2541.64, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 1", "code_information": [ { "code": "0571", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4449.24, "maximum": 4760.69, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "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": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4760.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "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": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 3", "code_information": [ { "code": "1793", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 40597.59, "maximum": 43439.42, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "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": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43439.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "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": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CCMCC", "code_information": [ { "code": "192", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6256, "minimum": 5894.07, "maximum": 12394.02, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9656.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6289.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10478.73, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 7996.94 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6256, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7395.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6228.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9756.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8132.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6256, "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": 6256, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11335.87, "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": 8795.94, "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": 9133.76, "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": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8132.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 7820, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6536.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6256, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6256, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10009.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8132.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9384, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6256, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5894.07 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6166.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9955.5 } ] } ] }, { "description": "Cystoscopy W/Biopsy(S)", "code_information": [ { "code": "52204", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11700, "discounted_cash": 2675, "minimum": 195.98, "maximum": 11700, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 195.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 205.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2995.78, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3745.57, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3761.63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3906.1, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 209.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3344.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2541.64, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 4", "code_information": [ { "code": "0574", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16634.03, "maximum": 17798.41, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "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": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17798.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "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": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 2", "code_information": [ { "code": "1142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4606.13, "maximum": 4928.56, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "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": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "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": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "286", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20971, "minimum": 4200, "maximum": 37999.905, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33024.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21076.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35194.67, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 24777.88 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20971.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 25489.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20869.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 33365.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 27262.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20971.25, "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": 20971.25, "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": 37999.91, "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": 29485.58, "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": 30618.03, "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": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 27262.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26214.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21903.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20971.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20971.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33554, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 27262.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 31456.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20971.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23995.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 20663.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34046 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 2", "code_information": [ { "code": "3462", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7614.7, "maximum": 8147.73, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "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": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8147.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "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": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Destruction Anal Lesion(S)", "code_information": [ { "code": "46910", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 2640, "minimum": 135.11, "maximum": 9400, "payers_information": [ { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% 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 Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net 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": 144.57 }, { "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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3432.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3300.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 135.11 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan 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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 135.11 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA 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": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 135.11 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3432.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3432.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2508.68, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 135.11 }, { "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry 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": 135.11 }, { "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 141.87 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2956.94, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2525.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 135.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "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": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "433", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10136, "minimum": 9735, "maximum": 20828.264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15962.51 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10189, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16833.23, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11636.83 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10136.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12166.37 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10089.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16127.08 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 13177.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10136.22, "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": 10136.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18366.83, "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": 14251.53, "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": 14798.88, "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": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13177.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12670.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10588.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10136.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10136.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16217.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13177.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15204.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10136.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11881.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9989.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16456.2 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "546", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11046, "minimum": 10030, "maximum": 20016.7835, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17274.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11104.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19581.08, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 13569.54 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11046.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13286.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10995.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17452.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14360.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11046.79, "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": 11046.79, "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": 20016.78, "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": 15531.79, "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": 16128.31, "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": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14360.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13808.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11539.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11046.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11046.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17674.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14360.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16570.19, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11046.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14794.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10886.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17808.3 } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 3", "code_information": [ { "code": "0953", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10607.36, "maximum": 11349.88, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "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": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11349.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "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": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 2", "code_information": [ { "code": "1792", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33373.01, "maximum": 35709.12, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "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": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35709.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "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": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 2", "code_information": [ { "code": "3842", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6140.1, "maximum": 6569.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "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": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6569.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "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": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 3", "code_information": [ { "code": "0423", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10008.4, "maximum": 10708.99, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "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": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10708.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "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": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Core Ndl Bx Lng/Med Perq", "code_information": [ { "code": "32408", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1879.75, "discounted_cash": 2113, "minimum": 563.925, "maximum": 9069.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "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": 878.63 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "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": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 922.56 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1879.75 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 878.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "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": 1879.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "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": 1879.75, "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": 1879.75, "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": 1879.75, "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": 940.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 878.63 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 878.63 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 878.63 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 878.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1879.75, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Clsd Tx Nsl Fx W/Mnpj&Stablj", "code_information": [ { "code": "21320", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8527, "discounted_cash": 4243, "minimum": 181.57, "maximum": 8527, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5422.22, "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": 181.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4328.21, "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": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 190.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4751.47, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1967.28 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6365.01, "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": 4285.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5589.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5940.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5966.14, "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": 6195.28, "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": 194.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5516.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5304.18, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4497.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5516.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5516.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4031.17, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5589.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC", "code_information": [ { "code": "057", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12378, "minimum": 11210, "maximum": 25549.232, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19910.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12442.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22257.09, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 13652.98 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12378.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14924.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12320.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20115.87 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 16092.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12378.92, "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": 12378.92, "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": 22430.6, "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": 17404.76, "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": 18073.22, "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": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16092.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15473.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12930.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12378.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12378.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19806.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16092.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 18568.38, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12378.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19020.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12198.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20526.4 } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1651", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 35209.1, "maximum": 37673.74, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "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": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37673.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "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": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 2", "code_information": [ { "code": "6612", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7714.35, "maximum": 8254.35, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8254.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "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": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITHOUT CCMCC", "code_information": [ { "code": "159", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6878, "minimum": 5900, "maximum": 37748.024, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9841.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11024.05, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 7587.62 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6878.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8161.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6848.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9943.37 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8942.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6878.97, "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": 6878.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12464.69, "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": 9671.83, "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": 10043.3, "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": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8942.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8598.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7187.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6878.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6878.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11006.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8942.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10318.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6878.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6860.51 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6780.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10146.3 } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1652", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38566.44, "maximum": 41266.09, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "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": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41266.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "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": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Colonoscopy And Biopsy", "code_information": [ { "code": "45380", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9270.8, "discounted_cash": 1531, "minimum": 473.68, "maximum": 9270.8, "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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 497.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1714.94, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1091.94 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 2297.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% 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 Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 506.84 }, { "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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1991, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan 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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA 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": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1991, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1991, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1454.96, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DEPRESSIVE NEUROSES", "code_information": [ { "code": "881", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9056, "minimum": 5400.83, "maximum": 18684, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13639.27 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9103.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14800.51, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9238.43 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9056.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10838.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9014.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13779.88 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11772.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9056.09, "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": 9056.09, "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": 16409.64, "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": 12732.86, "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": 13221.89, "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": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11772.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11320.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9460.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9056.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9056.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14489.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11772.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13584.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9056.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5400.83 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8925.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14061.1 } ] } ] }, { "description": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC", "code_information": [ { "code": "234", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 51416, "minimum": 23895, "maximum": 115728.792, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 62924.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 51162.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 80201.04 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 66841.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 51416.31, "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": 51416.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 93166.35, "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": 72291.33, "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": 75067.81, "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": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 66841.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 64270.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53695.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 51416.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 51416.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 82266.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 66841.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 77124.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 51416.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 75768.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81837.8 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 79382.67 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 51669.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 84866.58, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 58706.24 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 51416.31, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DIABETES - SOI : 3", "code_information": [ { "code": "4203", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7786.43, "maximum": 8331.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "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": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8331.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "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": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION WITH MCC", "code_information": [ { "code": "088", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12905, "minimum": 10620, "maximum": 34632.264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21049.1 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12971.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25042.49, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15663.49 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12905.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 15571.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12844.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21266.1 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 16777.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12905.4, "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": 12905.4, "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": 23384.58, "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": 18144.99, "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": 18841.88, "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": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16777.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16131.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13480.34, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12905.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12905.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20648.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16777.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 19358.1, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12905.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18433.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 12717.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21700.1 } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1662", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33063.46, "maximum": 35377.9, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "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": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35377.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "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": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 4", "code_information": [ { "code": "4204", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14323.01, "maximum": 15325.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "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": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15325.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "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": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 3", "code_information": [ { "code": "0573", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9804.86, "maximum": 10491.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "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": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10491.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "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": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Destroy ls facet jnt addl", "code_information": [ { "code": "64636", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3500, "minimum": 51.38, "maximum": 3500, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.95 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 871.26 }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.98 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 } ] }, { "setting": "outpatient", "gross_charge": 3500, "minimum": 51.38, "maximum": 3500, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.95 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 871.26 }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.98 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.38 } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1663", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39961.53, "maximum": 42758.84, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "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": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42758.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "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": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES WITH CC", "code_information": [ { "code": "638", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8637, "minimum": 7454.99, "maximum": 15650.8601, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13685.54 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8682.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14684.58, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9969.11 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8637.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10323.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8597.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13826.62 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11228.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8637.34, "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": 8637.34, "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": 15650.86, "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": 12144.1, "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": 12610.52, "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": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11228.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10796.68, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9023.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8637.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8637.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13819.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11228.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12956.01, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8637.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7454.99 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8512.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14108.8 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 3", "code_information": [ { "code": "3463", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11432.12, "maximum": 12232.37, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "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": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12232.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "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": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Destroy lumbsac facet jnt", "code_information": [ { "code": "64635", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8111.2, "discounted_cash": 2499, "minimum": 195.46, "maximum": 8111.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3193.55, "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": 195.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2549.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 205.23 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2798.5, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1503.53 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3748.83, "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": 2524.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3292.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3498.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "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": 2499.22, "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": 3513.9, "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": 3648.86, "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": 209.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3124.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2649.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2374.26, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3292.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 8111.2, "discounted_cash": 2499, "minimum": 195.46, "maximum": 8111.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3193.55, "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": 195.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2549.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 205.23 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2798.5, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1503.53 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3748.83, "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": 2524.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3292.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3498.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "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": 2499.22, "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": 3513.9, "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": 3648.86, "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": 209.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3124.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2649.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3248.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2374.26, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2499.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3292.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE", "code_information": [ { "code": "325", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30316, "minimum": 7965, "maximum": 54933.9872, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42705.41 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 30467.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43173.72, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 30316.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 36980.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 30168.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 43145.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 39411.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 30316.77, "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": 30316.77, "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": 54933.99, "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": 42625.38, "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": 44262.48, "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": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 39411.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 37895.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31662.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 30316.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30316.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 48506.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 39411.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 45475.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30316.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37397.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 29869.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44026.2 } ] } ] }, { "description": "DIABETES WITHOUT CCMCC", "code_information": [ { "code": "639", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6061, "minimum": 5398.48, "maximum": 26338.032, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9349.54 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6094.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10163.61, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 6914.44 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6061.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7155.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6034.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9445.93 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7879.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6061.14, "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": 6061.14, "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": 10982.79, "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": 8521.96, "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": 8849.26, "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": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 7879.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 7576.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6333.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6061.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6061.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9697.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 7879.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9091.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6061.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5398.48 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 5974.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9638.7 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "545", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23490, "minimum": 17110, "maximum": 42564.4417, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37703.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23607.8, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40706.7, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 28505.73 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 23490.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 28586.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23376.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 38092.6 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 30537.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23490.31, "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": 23490.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42564.44, "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": 33027.38, "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": 34295.85, "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": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 30537.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29362.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24533.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23490.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23490.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37584.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 30537.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 35235.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23490.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28533.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 23144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38870 } ] } ] }, { "description": "Corrj halux rigdus wo implt", "code_information": [ { "code": "28289", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13750, "discounted_cash": 4187, "minimum": 458.19, "maximum": 13750, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 458.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 481.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4689.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2576.58 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 490.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13750, "discounted_cash": 4187, "minimum": 458.19, "maximum": 13750, "payers_information": [ { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2576.58 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 490.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 458.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 481.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4689.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Diagnostic Colonoscopy", "code_information": [ { "code": "45378", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8523.7, "discounted_cash": 1190, "minimum": 423.48, "maximum": 8523.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1520.89, "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": 423.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1214.02, "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": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $1473", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 1473, "10th_percentile": 1473, "90th_percentile": 1473, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 444.65 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1332.75, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1091.94 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1785.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1666.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1673.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1737.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 453.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1547.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1487.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1261.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1547.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1547.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1130.71, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 3", "code_information": [ { "code": "3843", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8929.22, "maximum": 9554.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "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": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9554.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "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": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC", "code_information": [ { "code": "073", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15270, "minimum": 11505, "maximum": 31636.796, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23061.94 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15348.45, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24702.89, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15962.31 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15270.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18479.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15197.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23299.7 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 19852.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15270.82, "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": 15270.82, "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": 27670.73, "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": 21470.77, "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": 22295.4, "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": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 19852.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19088.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15950.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15270.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15270.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24433.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19852.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 22906.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15270.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17714 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15047.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23775.2 } ] } ] }, { "description": "Cor Hlx Vlgs Dstl Mtar Osteo", "code_information": [ { "code": "28296", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19062.5, "discounted_cash": 4187, "minimum": 574.61, "maximum": 19062.5, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4689.18, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3813.04 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 614.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5444.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.14, "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": 574.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "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": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $2454", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 2454, "10th_percentile": 2454, "90th_percentile": 2454, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 603.34 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "074", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9898, "minimum": 8260, "maximum": 20327.376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15553.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9949.91, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16754.86, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11141.82 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9898.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11873.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9852.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15714.01 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12867.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9898.27, "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": 9898.27, "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": 17935.67, "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": 13916.97, "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": 14451.47, "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": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12867.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12372.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10340.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9898.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9898.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15837.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12867.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14847.41, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9898.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11030 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9754.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16034.7 } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 2", "code_information": [ { "code": "2402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7210.8, "maximum": 7715.56, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "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": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7715.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "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": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "235", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 55218, "minimum": 23895, "maximum": 100056.4294, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87798.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 55490.04, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 96013.08, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 66354.75 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 55218.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 67600.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 54946.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 88703.33 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 71784.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 55218.78, "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": 55218.78, "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": 100056.43, "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": 77637.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 80619.42, "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": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 71784.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 69023.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 57666.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 55218.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 55218.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 88350.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 71784.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 82828.17, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 55218.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 71187.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 54402, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90513.6 } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "025", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42835, "minimum": 19175, "maximum": 89660.924, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 62539.44, "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": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 55685.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 53544.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44734.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 42835.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42835.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 68536.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 55685.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 64252.85, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42835.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50293.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68795 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66731.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 43046.45, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72100.43, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 49552.38 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 42835.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 52373.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 42624.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 67419.1 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 55685.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 42202.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 42835.23, "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": 42835.23, "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": 77617.44, "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": 60226.33, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 3", "code_information": [ { "code": "2403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10169.54, "maximum": 10881.41, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "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": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10881.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "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": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "236", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 39482, "minimum": 17110, "maximum": 97055.924, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61356.67 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 39677.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65981.03, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 45432.13 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 39482.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 48250.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 39288.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 61989.21 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 51327.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 39482.42, "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": 39482.42, "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": 71542.15, "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": 55512.28, "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": 57644.33, "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": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 51327.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 49353.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41233.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 39482.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 39482.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 63171.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 51327.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 59223.63, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 39482.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 57535.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 38899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63254.3 } ] } ] }, { "description": "Diag Laparo Separate Proc", "code_information": [ { "code": "49320", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15758.8, "discounted_cash": 7737, "minimum": 335.91, "maximum": 15758.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9887.07, "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": 335.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7892.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 352.71 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8663.99, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4532.96 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 11606.18, "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": 7814.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10192.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10832.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "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": 7737.45, "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": 10878.85, "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": 11296.68, "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": 359.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10058.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9671.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8201.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10058.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10058.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7350.58, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7737.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10192.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 1", "code_information": [ { "code": "9101", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22594.97, "maximum": 24176.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "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": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24176.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "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": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC", "code_information": [ { "code": "323", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40780, "minimum": 13570, "maximum": 73894.8458, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63554.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 40982.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67594.15, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 40780.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 49847.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 40580.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 64209.7 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 53015.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 40780.82, "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": 40780.82, "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": 73894.85, "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": 57337.83, "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": 59540, "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": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 53015.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 50976.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42589.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 40780.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40780.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 65249.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 53015.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 61171.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40780.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 62260.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 40178.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65520.1 } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH CC", "code_information": [ { "code": "375", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11573, "minimum": 10620, "maximum": 23853.312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18333.39 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11633, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19564.75, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 13613.51 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11573.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13933.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11518.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18522.39 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 15045.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11573.27, "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": 11573.27, "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": 20970.77, "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": 16272.02, "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": 16896.97, "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": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15045.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14466.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12089.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11573.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11573.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18517.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15045.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17359.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11573.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13509.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11404.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18900.4 } ] } ] }, { "description": "CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC", "code_information": [ { "code": "024", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 36888, "minimum": 11505, "maximum": 77142.668, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56725.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 37070.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61860.07, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 45290.05 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 36888.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 45061.18 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 36707.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 57310.01 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 47954.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 36888.42, "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": 36888.42, "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": 66841.82, "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": 51865.12, "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": 53857.09, "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": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 47954.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 46110.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38524.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 36888.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36888.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 59021.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 47954.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 55332.63, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36888.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 45888.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 36344, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58479.6 } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC", "code_information": [ { "code": "324", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29760, "minimum": 6785, "maximum": 98351.528, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47674.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 29908.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48468.6, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 29760.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 36296.37 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 29615.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 48165.53 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 38688.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 29760.31, "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": 29760.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 53925.68, "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": 41843, "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": 43450.05, "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": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 38688.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 37200.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31081.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 29760.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29760.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 47616.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 38688.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 44640.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29760.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46931.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 29321.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49148.5 } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 3", "code_information": [ { "code": "5173", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12821.91, "maximum": 13719.44, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "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": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13719.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "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": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Create Eardrum Opening", "code_information": [ { "code": "69436", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9792.63, "discounted_cash": 1985, "minimum": 173.03, "maximum": 9792.63, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2537.51, "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": 173.03 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2025.53, "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": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $2127", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 2127, "10th_percentile": 2127, "90th_percentile": 2127, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.68 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2223.61, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1967.28 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.03 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 2978.72, "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": 2005.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2616.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "CIGNA", "plan_name": "Cigna Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 40, "median_amount": 2100, "10th_percentile": 555.91, "90th_percentile": 4200, "count": "1 through 10" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2780.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "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": 1985.81, "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": 2792.05, "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": 2899.28, "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": 185.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2581.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2482.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.03 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2104.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 173.03 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.03 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2581.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2581.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1886.52, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.03 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1985.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2616.01, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 1", "code_information": [ { "code": "5171", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6167.66, "maximum": 6599.4, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "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": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6599.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "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": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CPTRASST DIR MS PX", "code_information": [ { "code": "20985", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24127.49, "minimum": 110.95, "maximum": 24127.49, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 184.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Exchange (09-01-2023 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 154.11 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.5 }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.72 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 } ] }, { "setting": "outpatient", "gross_charge": 24127.5, "minimum": 110.95, "maximum": 24127.49, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 184.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Exchange (09-01-2023 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 154.11 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.5 }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.72 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.95 } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 2", "code_information": [ { "code": "0452", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8072.66, "maximum": 8637.75, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "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": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8637.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "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": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 4", "code_information": [ { "code": "5174", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21946.19, "maximum": 23482.42, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "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": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23482.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "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": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "027", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23876, "minimum": 4720, "maximum": 49751.588, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36822.07 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23995.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39722.17, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 27025.19 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 23876.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 29061.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23760.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 37201.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 31039.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23876.27, "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": 23876.27, "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": 43263.8, "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": 33570.04, "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": 34859.35, "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": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 31039.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29845.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24936.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23876.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23876.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38202.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 31039.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 35814.41, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23876.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33378.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 23525.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37960.9 } ] } ] }, { "description": "Dilation And Curettage", "code_information": [ { "code": "58120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 4143, "minimum": 319.8, "maximum": 9400, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 342.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3935.93, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.11, "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": 319.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "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": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.79 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4639.21, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2406.49 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA", "code_information": [ { "code": "955", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 63298, "minimum": 25960, "maximum": 117833, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 101885.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 63609.04, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99435.24, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 68563.72 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 63298.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 77535.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 62985.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 102935.48 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 82288.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 63298.68, "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": 63298.68, "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": 114697.21, "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": 88997.94, "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": 92416.07, "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": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 82288.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 79123.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 66103.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 63298.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 63298.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 101277.89, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 82288.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 94948.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 63298.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 117833 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 62361.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 105036.2 } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 1", "code_information": [ { "code": "7521", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2817.75, "maximum": 3014.99, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "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": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3014.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "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": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 2", "code_information": [ { "code": "1312", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12532.5, "maximum": 13409.78, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "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": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13409.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "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": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 2", "code_information": [ { "code": "9102", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22650.1, "maximum": 24235.61, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "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": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24235.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "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": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 4", "code_information": [ { "code": "7524", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33313.64, "maximum": 35645.59, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "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": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35645.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "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": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cystoscopy And Treatment - 52240 - OR36052240", "code_information": [ { "code": "52240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24600, "discounted_cash": 6862, "minimum": 961.25, "maximum": 24600, "payers_information": [ { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8768.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6999.62, "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": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1009.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7684.13, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 10293.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6930.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9607.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9648.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10019.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1028.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8577.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7274.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6519.25, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 961.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 1", "code_information": [ { "code": "2841", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5267.64, "maximum": 5636.37, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "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": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5636.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "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": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 3", "code_information": [ { "code": "0453", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10803.48, "maximum": 11559.72, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "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": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11559.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "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": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITH CC", "code_information": [ { "code": "445", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10494, "minimum": 8850, "maximum": 21581.568, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16181.83 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10548.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17744.28, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 12116.06 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10494.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 12606.39 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10445.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16348.65 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 13642.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10494.08, "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": 10494.08, "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": 19015.27, "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": 14754.68, "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": 15321.36, "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": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13642.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13117.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10962.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10494.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10494.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16790.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13642.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15741.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10341.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16682.3 } ] } ] }, { "description": "Cystoscopy And Treatment - 52300 - OR36052300", "code_information": [ { "code": "52300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12500, "discounted_cash": 4511, "minimum": 326.3, "maximum": 12500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 326.3 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 342.62 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 326.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 349.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 326.3 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 326.3 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 326.3 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 326.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 4", "code_information": [ { "code": "2844", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17059.13, "maximum": 18253.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "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": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18253.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "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": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 1", "code_information": [ { "code": "1311", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7099.49, "maximum": 7596.45, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "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": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7596.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "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": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 1", "code_information": [ { "code": "2441", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4359.13, "maximum": 4664.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "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": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4664.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "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": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTOURETERO & OR PYELOSCOPE", "code_information": [ { "code": "52351", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11979.17, "discounted_cash": 4511, "minimum": 260.61, "maximum": 11979.17, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 273.64 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 278.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 11979.2, "discounted_cash": 4511, "minimum": 260.61, "maximum": 11979.17, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 273.64 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 278.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 260.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 3", "code_information": [ { "code": "2823", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9386.13, "maximum": 10043.16, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "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": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10043.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "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": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 4", "code_information": [ { "code": "1314", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18877.2, "maximum": 20198.6, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "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": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20198.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "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": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CCMCC", "code_information": [ { "code": "744", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19437, "minimum": 13275, "maximum": 35221.1305, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29155.68 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19535.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30734.11, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 19625.88 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 19437.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 23603.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19344.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29456.25 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 25269.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19437.71, "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": 19437.71, "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": 35221.13, "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": 27329.42, "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": 28379.06, "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": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 25269.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24297.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20301.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19437.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19437.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31100.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25269.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 29156.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19437.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17944.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19152.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30057.4 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 4", "code_information": [ { "code": "2824", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 20005.15, "maximum": 21405.51, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "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": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21405.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "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": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTO RX BALO CATH URTL STRX", "code_information": [ { "code": "52284", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16041.7, "discounted_cash": 6862, "minimum": 3436, "maximum": 16041.67, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8768.87, "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": 6999.62, "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": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7684.13, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7296.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 10293.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6930.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9607.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9648.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10019.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8577.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7274.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6519.25, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 16041.67, "discounted_cash": 6862, "minimum": 3436, "maximum": 16041.67, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8768.87, "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": 6999.62, "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": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7684.13, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7296.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 10293.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6930.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9607.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9648.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10019.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8577.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7274.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6519.25, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Dbrdmt musc&fsca ea addl", "code_information": [ { "code": "11046", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3437.5, "minimum": 31.27, "maximum": 3437.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.83 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 321.63 }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.46 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 } ] }, { "setting": "outpatient", "gross_charge": 3437.5, "minimum": 31.27, "maximum": 3437.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.83 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 321.63 }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.46 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.27 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC", "code_information": [ { "code": "438", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15513, "minimum": 14160, "maximum": 32147.544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24824.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15592.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27246.65, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 18473.47 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15513.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18778.27 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15439.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25079.96 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20167.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15513.45, "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": 15513.45, "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": 28110.37, "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": 21811.91, "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": 22649.64, "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": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20167.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19391.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16203.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15513.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15513.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24821.52, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20167.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23270.18, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15513.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19218.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15286.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25591.8 } ] } ] }, { "description": "Cysto/Uretero W/Lithotripsy", "code_information": [ { "code": "52356", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20990.7, "discounted_cash": 6862, "minimum": 354.06, "maximum": 20990.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8768.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6999.62, "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": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.76 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7684.13, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5188.47 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 10293.56, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6930.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9607.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9648.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10019.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 378.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8577.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7274.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8921.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6519.25, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 354.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6862.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9040.14, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Deb skin bone at fx site", "code_information": [ { "code": "11012", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13750, "discounted_cash": 3717, "minimum": 515.6468, "maximum": 13750, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 552.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 515.65 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 590.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13750, "discounted_cash": 3717, "minimum": 515.6468, "maximum": 13750, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 552.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.8 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 515.65 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 590.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 552.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 2", "code_information": [ { "code": "7522", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3671.13, "maximum": 3928.11, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "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": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3928.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cystoscopy And Treatment - 52315 - OR36052315", "code_information": [ { "code": "52315", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15625, "discounted_cash": 2675, "minimum": 526.96, "maximum": 15625, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 526.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 553.31 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2995.78, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3063.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 526.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3745.57, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3761.63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3906.1, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 563.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3344.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 526.96 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 526.96 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 526.96 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2541.64, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 526.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 1", "code_information": [ { "code": "3041", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21066.31, "maximum": 22540.95, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "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": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22540.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "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": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 2", "code_information": [ { "code": "0422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7420.7, "maximum": 7940.15, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "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": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7940.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "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": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITH MCC", "code_information": [ { "code": "444", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15894, "minimum": 13275, "maximum": 32950.148, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25132.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15975.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26665.4, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 18335.9 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15894.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19247.1 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15818.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25392 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20663.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15894.73, "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": 15894.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28801.25, "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": 22347.99, "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": 23206.31, "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": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20663.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19868.41, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16601.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15894.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15894.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25431.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20663.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23842.1, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15894.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15763.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25910.2 } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CCMCC", "code_information": [ { "code": "745", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10897, "minimum": 5120.66, "maximum": 34255.612, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15291.08 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 10954.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16913.23, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 12012.32 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 10897.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13102.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10846.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15448.72 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14167.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10897.84, "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": 10897.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19746.89, "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": 15322.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15910.85, "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": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14167.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13622.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11383.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10897.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10897.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17436.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14167.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16346.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10897.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5120.66 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 10739.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15764 } ] } ] }, { "description": "Drain/Inj Joint/Bursa W/O Us", "code_information": [ { "code": "20610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9124.66, "discounted_cash": 392, "minimum": 65.68, "maximum": 9124.66, "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.96 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 439.9, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 304.48 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield 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 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% 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 Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 510.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan 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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA 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": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 510.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 510.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 373.22, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 1", "code_information": [ { "code": "1141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3289.49, "maximum": 3519.75, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "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": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3519.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "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": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 2", "code_information": [ { "code": "2442", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5831.61, "maximum": 6239.82, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "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": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6239.82, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "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": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 2", "code_information": [ { "code": "7702", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3378.54, "maximum": 3615.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "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": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3615.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "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": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 4", "code_information": [ { "code": "1144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15815.63, "maximum": 16922.72, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "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": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16922.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "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": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 3", "code_information": [ { "code": "2443", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8730.98, "maximum": 9342.15, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "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": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9342.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "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": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Debride Nail 6 Or More", "code_information": [ { "code": "11721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 75, "minimum": 47.52, "maximum": 9400, "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": 47.52 }, { "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.9 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.54, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 102.4 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% 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 Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net 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": 50.85 }, { "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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 94.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.52 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan 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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 47.52 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA 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": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.52 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.73, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.52 }, { "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC", "code_information": [ { "code": "147", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12153, "minimum": 10325, "maximum": 26257.18, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18765.14 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 15799.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12153.15, "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": 12153.15, "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": 22021.51, "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": 17087.33, "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": 17743.6, "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": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15799.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15191.44, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12694.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12153.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12153.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19445.04, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15799.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 18229.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12153.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14317.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19148.1 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18573.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12215.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20177.02, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11976.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 13992.39 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12153.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14646.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12095.96, "additional_payer_notes": "101.00% of Medicare Rates" } ] } ] }, { "description": "DEEP VEIN THROMBOPHLEBITIS WITH CCMCC", "code_information": [ { "code": "294", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10030, "maximum": 18889.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18323.01 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17856.94, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 14341.94 }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18511.91 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16045.9 }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18889.7 } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC", "code_information": [ { "code": "146", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20077, "minimum": 13339.3968, "maximum": 36380.5025, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34230.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20178.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34466.48, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 21746.89 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20077.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24390.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19980.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34583.12 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 26100.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20077.54, "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": 20077.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36380.5, "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": 28229.02, "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": 29313.21, "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": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26100.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25096.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20969.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20077.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20077.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32124.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 26100.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 30116.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20077.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16779.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19782.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35288.9 } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 2", "code_information": [ { "code": "3042", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28158.38, "maximum": 30129.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "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": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30129.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "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": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 1", "code_information": [ { "code": "1101", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6412.54, "maximum": 6861.42, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "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": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6861.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "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": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 4", "code_information": [ { "code": "3034", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 74045.86, "maximum": 79229.07, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "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": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 79229.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "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": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 1", "code_information": [ { "code": "1791", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28107.49, "maximum": 30075.01, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "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": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30075.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "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": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 4", "code_information": [ { "code": "1104", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17487.41, "maximum": 18711.53, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "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": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18711.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "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": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 2", "code_information": [ { "code": "4202", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5392.73, "maximum": 5770.22, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "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": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5770.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "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": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Drain Bl W/Cath Insertion", "code_information": [ { "code": "51102", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 2675, "minimum": 275.5, "maximum": 9400, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3906.1, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 294.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3344.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 275.5 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2835.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 275.5 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 275.5 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3478.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2541.64, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 275.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3418.69, "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": 275.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2728.92, "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": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 289.28 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2995.78, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2383.26 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 275.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 4013.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2702.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3524.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3745.57, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2675.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3761.63, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 4", "code_information": [ { "code": "1794", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54992.69, "maximum": 58842.18, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "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": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58842.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "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": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 2", "code_information": [ { "code": "7592", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8406.59, "maximum": 8995.05, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "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": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8995.05, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "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": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 4", "code_information": [ { "code": "2404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15872.88, "maximum": 16983.98, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "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": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16983.98, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "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": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 3", "code_information": [ { "code": "7703", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5481.78, "maximum": 5865.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "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": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5865.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "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": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 1", "code_information": [ { "code": "0421", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5906.88, "maximum": 6320.36, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "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": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6320.36, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "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": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Egd Remove Lesion Snare", "code_information": [ { "code": "43251", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 2455, "minimum": 1475.2936, "maximum": 12096.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3138.25, "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": 2505.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2750.03, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1475.29 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3683.91, "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": 2480.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3235.33, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3438.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "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": 2455.94, "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": 3453.05, "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": 3585.67, "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": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3192.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3069.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2603.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3192.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3192.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2333.14, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3235.33, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH MCC", "code_information": [ { "code": "374", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20277, "minimum": 16520, "maximum": 42175.164, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31504.24 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20378.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34270.56, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 22523.81 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 20277.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 24635.69 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20179.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31829.03 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 26360.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20277.08, "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": 20277.08, "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": 36742.07, "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": 28509.57, "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": 29604.54, "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": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26360.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25346.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21178.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20277.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20277.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32443.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 26360.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 30415.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20277.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25577.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 19979.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32478.6 } ] } ] }, { "description": "EATING DISORDERS - SOI : 1", "code_information": [ { "code": "7591", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6174.02, "maximum": 6606.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "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": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6606.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "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": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 4", "code_information": [ { "code": "0424", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18420.3, "maximum": 19709.72, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "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": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19709.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "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": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 4", "code_information": [ { "code": "3244", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29312.83, "maximum": 31364.73, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "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": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31364.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "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": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "376", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8900, "minimum": 6785, "maximum": 18227.196, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13175.22 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8947.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14553.97, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11290.66 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8900.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10647.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8859.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13311.05 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11570.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8900.58, "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": 8900.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16127.85, "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": 12514.22, "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": 12994.85, "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": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11570.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11125.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9298.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8900.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8900.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14240.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11570.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13350.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8900.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10456.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8771.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13582.7 } ] } ] }, { "description": "ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES", "code_information": [ { "code": "003", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 199079, "minimum": 71095, "maximum": 418560.944, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 319780.97 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 200047.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 348098.44, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 213724.18 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 199079.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 244493.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 198086.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 323077.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 258803.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 199079.41, "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": 199079.41, "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": 360731.89, "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": 279905.65, "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": 290655.94, "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": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 258803.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 248849.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 207892.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 199079.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 199079.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 318527.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 258803.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 298619.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 199079.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 304349 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 196125, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 329671.1 } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC", "code_information": [ { "code": "056", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22004, "minimum": 17700, "maximum": 45811.532, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37363.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22114.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39087.05, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 24721.5 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 22004.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 26759.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21898.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 37748.91 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 28605.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22004.54, "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": 22004.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39872.23, "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": 30938.38, "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": 32126.63, "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": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 28605.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27505.68, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22982.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22004.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22004.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35207.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 28605.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 33006.81, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22004.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28482.7 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 21681.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38519.3 } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 4", "code_information": [ { "code": "3264", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25927.93, "maximum": 27742.89, "payers_information": [ { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "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": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27742.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "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": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Egd Diagnostic Brush Wash", "code_information": [ { "code": "43235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5354, "discounted_cash": 1160, "minimum": 321.48, "maximum": 6026.29, "payers_information": [ { "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": 321.48 }, { "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" }, { "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 337.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1299.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 985.13 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% 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 Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net 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": 343.98 }, { "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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.48 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan 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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 321.48 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA 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": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.48 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1102.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.48 }, { "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITH CC", "code_information": [ { "code": "158", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8764, "minimum": 8260, "maximum": 49773.28, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14034.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8810.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15322.97, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9771.78 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8764.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 10479.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8724.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14179.42 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11394.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8764.75, "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": 8764.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15881.73, "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": 12323.24, "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": 12796.54, "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": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11394.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10955.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9156.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8764.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8764.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14023.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11394.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13147.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8764.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9660.99 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14468.8 } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH MCC", "code_information": [ { "code": "643", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15662, "minimum": 14750, "maximum": 28380.2688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24728.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15741.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26859.69, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 18329.14 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 15662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 18961.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15587.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24983.53 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20361.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15662.4, "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": 15662.4, "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": 28380.27, "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": 22021.33, "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": 22867.1, "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": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20361.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19578, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16359.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25059.84, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20361.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23493.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17452.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 15433.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25493.4 } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 2", "code_information": [ { "code": "2842", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7392.08, "maximum": 7909.53, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "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": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7909.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "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": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 1", "code_information": [ { "code": "3241", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12305.64, "maximum": 13167.03, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "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": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13167.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "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": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITH MCC", "code_information": [ { "code": "157", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16324, "minimum": 12980, "maximum": 88381.096, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24433.14 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16407.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27870.34, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 17623.26 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 16324.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 19775.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16246.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24685.02 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 21222.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16324.72, "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": 16324.72, "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": 29580.39, "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": 22952.56, "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": 23834.09, "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": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 21222.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20405.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17050.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16324.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16324.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26119.55, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 21222.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 24487.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16324.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19026.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16085.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25188.8 } ] } ] }, { "description": "ENDOMETR ABLATE THERMAL", "code_information": [ { "code": "58353", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 6402, "minimum": 1067.62, "maximum": 10500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.18, "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": 1067.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $4091", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 4091, "10th_percentile": 4091, "90th_percentile": 4091, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1121 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7169.13, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4200.45 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "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": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8963.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "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": 6402.45, "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": 9001.84, "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": 9347.58, "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": 1142.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 6402, "minimum": 1067.62, "maximum": 10500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.18, "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": 1067.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "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": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Commercial (09-01-2023 to 12-31-26)", "methodology": "percent of total billed charges", "standard_charge_percentage": 92.12, "standard_charge_algorithm": "Not To Exceed $4091", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 4091, "10th_percentile": 4091, "90th_percentile": 4091, "count": "1 through 10" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1121 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7169.13, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4200.45 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "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": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8963.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "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": 6402.45, "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": 9001.84, "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": 9347.58, "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": 1142.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8323.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1067.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "442", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9284, "minimum": 9150.32, "maximum": 19035.716, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11119.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9241.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14565.25 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12070.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9284.67, "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": 9284.67, "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": 16823.82, "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": 13054.25, "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": 13555.62, "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": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12070.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11605.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9699.34, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9284.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9284.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14855.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12070.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 13927.01, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9284.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10978.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14862.5 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14416.63 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9333.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15535.23, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9150.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 10525.02 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9284.67, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 3", "code_information": [ { "code": "3263", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18607.94, "maximum": 19910.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "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": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19910.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "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": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 3", "code_information": [ { "code": "1143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6926.69, "maximum": 7411.56, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "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": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7411.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "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": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOSCOPIC INJECTIONIMPLANT", "code_information": [ { "code": "51715", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17187.5, "discounted_cash": 4511, "minimum": 234.44, "maximum": 17187.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 246.16 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3766.82 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 250.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 17187.5, "discounted_cash": 4511, "minimum": 234.44, "maximum": 17187.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "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": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 246.16 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5051.73, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3766.82 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "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": 6586.78, "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": 250.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5864.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 2", "code_information": [ { "code": "2822", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5998.05, "maximum": 6417.91, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "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": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6417.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "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": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "440", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6063, "minimum": 5976.53, "maximum": 12254.008, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9177.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6096.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10050.96, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 6941.51 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6063.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 7157.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6036.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9272.56 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7881.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6063.02, "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": 6063.02, "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": 10986.19, "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": 8524.61, "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": 8852.01, "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": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 7881.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 7578.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6335.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6063.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6063.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9700.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 7881.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9094.53, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6063.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6742.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 5976.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9461.8 } ] } ] }, { "description": "Endo Cholangiopancreatograph - 43262 - OR36043262", "code_information": [ { "code": "43262", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20900, "discounted_cash": 4934, "minimum": 531.36, "maximum": 22868, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6305.38, "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": 531.36 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5033.17, "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": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 557.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5525.37, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2879.33 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 531.36 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 7401.72, "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": 4983.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6908.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "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": 4934.48, "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": 6937.88, "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": 7204.34, "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": 568.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6414.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6168.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 531.36 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5230.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 531.36 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 531.36 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6414.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6414.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4687.76, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 531.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500.44, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY AND IMPULSE CONTROL", "code_information": [ { "code": "883", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18662, "minimum": 14430.9, "maximum": 33815.6165, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27662.07 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18756.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30619.82, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15071.5 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 18662.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 22649.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18572.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27947.25 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24260.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18662.04, "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": 18662.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33815.62, "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": 26238.83, "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": 27246.58, "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": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 24260.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23327.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19491.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18662.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18662.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29859.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 24260.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 27993.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18662.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14430.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 18388.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28517.6 } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH CC", "code_information": [ { "code": "644", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9843, "minimum": 9663.34, "maximum": 17837.2193, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15419.41 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9895.31, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17334.47, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 11592.86 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 9843.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 11806.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9798.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15578.37 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12797.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9843.94, "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": 9843.94, "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": 17837.22, "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": 13840.58, "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": 14372.15, "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": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12797.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12304.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10283.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9843.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9843.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15750.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12797.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14765.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9843.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9663.34 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 9701.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15896.3 } ] } ] }, { "description": "Ercp Ea Duct/Ampulla Dilate", "code_information": [ { "code": "43277", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 4934, "minimum": 344.01, "maximum": 21423.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6305.38, "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": 344.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5033.17, "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": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 361.21 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5525.37, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3254.39 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 7401.72, "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": 4983.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6908.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "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": 4934.48, "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": 6937.88, "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": 7204.34, "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": 368.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6414.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6168.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5230.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6414.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6414.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4687.76, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500.44, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 4", "code_information": [ { "code": "2444", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15668.28, "maximum": 16765.06, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "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": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16765.06, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "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": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOCRINE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "645", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7439, "minimum": 6062.4, "maximum": 92711.608, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11618.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7478.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12423.28, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8628.4 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7439.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8850.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7405.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11738.73 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9670.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7439.17, "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": 7439.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13479.78, "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": 10459.47, "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": 10861.19, "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": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9670.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9298.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7772.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7439.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7439.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11902.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9670.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11158.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7439.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6062.4 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7332.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11978.3 } ] } ] }, { "description": "DIABETES - SOI : 1", "code_information": [ { "code": "4201", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4059.12, "maximum": 4343.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "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": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4343.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "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": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES WITH MCC", "code_information": [ { "code": "637", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13700, "minimum": 11800, "maximum": 24825.759, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21729.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13770.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23662.85, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 15625.15 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 13700.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 16549.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13635.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21953.47 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17810.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13700.75, "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": 13700.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24825.76, "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": 19263.25, "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": 20003.1, "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": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 17810.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17125.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14310.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13700.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13700.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21921.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17810.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 20551.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13700.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12588.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 13500.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22401.5 } ] } ] }, { "description": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC", "code_information": [ { "code": "391", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12123, "minimum": 11210, "maximum": 25010.876, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19166.04 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12185.63, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20828.47, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 13925.86 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 12123.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 14609.55 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12066.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19363.62 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 15760.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12123.17, "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": 12123.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21967.18, "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": 17045.18, "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": 17699.83, "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": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 15760.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15153.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12663.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12123.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12123.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19397.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15760.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 18184.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12123.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12191.9 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11946.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19758.8 } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 3", "code_information": [ { "code": "3043", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38877.05, "maximum": 41598.44, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "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": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41598.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "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": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Forearm Tum Deep 3 Cm/>", "code_information": [ { "code": "25073", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11700, "discounted_cash": 3717, "minimum": 439.31, "maximum": 11700, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 439.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 461.28 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 439.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 470.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 439.31 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 439.31 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 439.31 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 439.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 1", "code_information": [ { "code": "3031", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 32600.2, "maximum": 34882.21, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "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": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34882.21, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "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": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg >4 cm", "code_information": [ { "code": "11426", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5833.33, "discounted_cash": 3717, "minimum": 344.44, "maximum": 5833.33, "payers_information": [ { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 368.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 344.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 361.66 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 2", "code_information": [ { "code": "3032", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 36947.67, "maximum": 39534.01, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "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": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39534.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "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": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 1", "code_information": [ { "code": "2401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5584.61, "maximum": 5975.53, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "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": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "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": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Neck Les Sc < 3 Cm", "code_information": [ { "code": "21555", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9677, "discounted_cash": 2113, "minimum": 474.74, "maximum": 9677, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 474.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 498.48 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2366.95, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1982.46 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 507.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Ercp stent exchange wdilate", "code_information": [ { "code": "43276", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3437.5, "discounted_cash": 7769, "minimum": 431.5, "maximum": 3437.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "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": 431.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "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": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 453.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3437.5 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "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": 3437.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "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": 3437.5, "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": 3437.5, "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": 3437.5, "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": 461.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 3437.5, "discounted_cash": 7769, "minimum": 431.5, "maximum": 3437.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "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": 431.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "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": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 453.08 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3437.5 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "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": 3437.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "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": 3437.5, "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": 3437.5, "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": 3437.5, "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": 461.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 431.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3437.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 2", "code_information": [ { "code": "5172", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8522.14, "maximum": 9118.69, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "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": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9118.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "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": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Neck Tum Deep < 5 Cm", "code_information": [ { "code": "21556", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16025, "discounted_cash": 3717, "minimum": 572.48, "maximum": 16025, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 572.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 601.1 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 612.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 572.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DRAINAGE OF HYDROCELE", "code_information": [ { "code": "55000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4375, "discounted_cash": 906, "minimum": 80.11, "maximum": 4375, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.1, "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": 80.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "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": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.12 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1014.84, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 533.23 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 85.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 860.99, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 4375, "discounted_cash": 906, "minimum": 80.11, "maximum": 4375, "payers_information": [ { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 860.99, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.1, "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": 80.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "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": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.12 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1014.84, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 533.23 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 85.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.11 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Exc rect tum transanal full", "code_information": [ { "code": "45172", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 3552, "minimum": 673.12, "maximum": 10500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4539.42, "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": 673.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.52, "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": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 706.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3977.87, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2844.81 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5328.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3587.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4973.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4994.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5186.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 720.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4618.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3765.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4618.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4618.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3374.85, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 3552, "minimum": 673.12, "maximum": 10500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4539.42, "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": 673.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.52, "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": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 706.78 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3977.87, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2844.81 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5328.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3587.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4973.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4994.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5186.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 720.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4618.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3765.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4618.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4618.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3374.85, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 673.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 1", "code_information": [ { "code": "7701", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2155.18, "maximum": 2306.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "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": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2306.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "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": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Esoph Egd Dilation <30 Mm", "code_information": [ { "code": "43249", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5354, "discounted_cash": 2455, "minimum": 319.89, "maximum": 9677.23, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3138.25, "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": 319.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2505.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.88 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2750.03, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1475.29 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3683.91, "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": 2480.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3235.33, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3438.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "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": 2455.94, "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": 3453.05, "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": 3585.67, "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": 342.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3192.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3069.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.89 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2603.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 319.89 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.89 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3192.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3192.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2333.14, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 319.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3235.33, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 3", "code_information": [ { "code": "2843", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9985.08, "maximum": 10684.04, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "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": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10684.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "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": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Rect Tum Transanal Part", "code_information": [ { "code": "45171", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 3552, "minimum": 494.41, "maximum": 9400, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4539.42, "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": 494.41 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.52, "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": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 519.13 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3977.87, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2844.81 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5328.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3587.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4973.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4994.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5186.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 529.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4618.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3765.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4618.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4618.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3374.85, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 4", "code_information": [ { "code": "7704", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10998.54, "maximum": 11768.44, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "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": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11768.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "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": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "392", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7545, "minimum": 7375, "maximum": 15373.712, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11642.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7585.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12826.56, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8586.67 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7545.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8980.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7510.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11762.84 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9808.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7545.03, "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": 7545.03, "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": 13671.59, "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": 10608.31, "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": 11015.74, "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": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9808.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9431.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7882.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7545.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7545.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12072.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9808.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11317.55, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7545.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7591.54 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7436.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12002.9 } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "441", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17054, "minimum": 14160, "maximum": 35391.484, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28206.63 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17140.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29849.18, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 20866.24 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17054.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 20673.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16972.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28497.42 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 22170.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17054.49, "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": 17054.49, "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": 30902.74, "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": 23978.61, "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": 24899.56, "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": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 22170.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21318.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17812.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17054.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17054.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27287.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22170.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 25581.74, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17054.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21289 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 16804.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29079 } ] } ] }, { "description": "Excise Parotid Gland/Lesion", "code_information": [ { "code": "42415", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48750, "discounted_cash": 7576, "minimum": 876.88, "maximum": 48750, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9681.51, "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": 876.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7728.11, "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": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 920.72 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8483.86, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5268.64 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 876.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 11364.87, "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": 7652.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9981.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10607.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "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": 7576.58, "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": 10652.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11061.81, "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": 938.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9849.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9470.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 876.88 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8031.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 876.88 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 876.88 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9849.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9849.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7197.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 876.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7576.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9981.01, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 3", "code_information": [ { "code": "1103", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10282.97, "maximum": 11002.78, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "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": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11002.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "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": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Esophagoscopy flexible brush", "code_information": [ { "code": "43200", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3133.33, "discounted_cash": 1160, "minimum": 241.91, "maximum": 3133.33, "payers_information": [ { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net 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": 258.84 }, { "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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan 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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA 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": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1102.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% 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": 241.91 }, { "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" }, { "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.01 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1299.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 985.13 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% 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" } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "443", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6796, "minimum": 6699.15, "maximum": 13798.084, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10485.02 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6833.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11668.97, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 7671.06 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 6796.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8059.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6766.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10593.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8835.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6796.53, "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": 6796.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12315.31, "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": 9555.92, "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": 9922.93, "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": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 8835.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8495.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7101.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6796.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6796.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10874.45, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8835.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10194.8, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6796.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7070.05 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 6699.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10809.3 } ] } ] }, { "description": "Excision Of Tongue Lesion - 41113 - OR36041113", "code_information": [ { "code": "41113", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10950, "discounted_cash": 4243, "minimum": 1787, "maximum": 10950, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5422.22, "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": 4328.21, "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": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4751.47, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1967.28 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6365.01, "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": 4285.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5589.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5940.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5966.14, "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": 6195.28, "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": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5516.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5304.18, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4497.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5516.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5516.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4031.17, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4243.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5589.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 2", "code_information": [ { "code": "3242", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13814.16, "maximum": 14781.15, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "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": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14781.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "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": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 1", "code_information": [ { "code": "2821", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4490.58, "maximum": 4804.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "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": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4804.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "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": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 3", "code_information": [ { "code": "9113", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29241.8, "maximum": 31288.73, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "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": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31288.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "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": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 2", "code_information": [ { "code": "3262", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12960.78, "maximum": 13868.03, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "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": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13868.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "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": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Evacuate Mole Of Uterus", "code_information": [ { "code": "59870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 4143, "minimum": 436.09, "maximum": 9400, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 457.89 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4639.21, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2406.49 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 436.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 466.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 436.09 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 436.09 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 436.09 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5386, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3935.93, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 436.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.11, "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": 436.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "additional_payer_notes": "102.00% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC", "code_information": [ { "code": "439", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8122, "minimum": 8005.02, "maximum": 16588.464, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12835.04 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8165.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13962.93, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9553.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 8122.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9689.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8085.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12967.36 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10558.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8122.1, "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": 8122.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14717.25, "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": 11419.67, "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": 11858.27, "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": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10558.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10152.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8485.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8122.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8122.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12995.36, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10558.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 12183.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8122.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8971.17 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 8005.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13232 } ] } ] }, { "description": "EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT", "code_information": [ { "code": "927", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 200253, "minimum": 70800, "maximum": 430360.84, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 353967.94 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 201227.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 430360.84, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 224882.91 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 200253.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 245936.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 199254.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 357617.09 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 260329.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 200253.22, "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": 200253.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 362858.83, "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": 281556.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 292369.7, "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": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 260329.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 250316.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 209118.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 200253.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 200253.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 320405.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 260329.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 300379.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 200253.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 309974 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 197282, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 364915.4 } ] } ] }, { "description": "Endo cholangiopancreatograph - 43261 - ", "code_information": [ { "code": "43261", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8593.76, "discounted_cash": 4934, "minimum": 489.17, "maximum": 8593.76, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6305.38, "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": 489.17 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5033.17, "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": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 513.63 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5525.37, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2879.33 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 489.17 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 7401.72, "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": 4983.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6908.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "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": 4934.48, "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": 6937.88, "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": 7204.34, "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": 523.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6414.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6168.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 489.17 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5230.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 489.17 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 489.17 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6414.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6414.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4687.76, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 489.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500.44, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Exc Face Les Sbq 2 Cm/>", "code_information": [ { "code": "21012", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11700, "discounted_cash": 2113, "minimum": 281.09, "maximum": 11700, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 281.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2366.95, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 964.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 300.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 281.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 3", "code_information": [ { "code": "7523", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7618.94, "maximum": 8152.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "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": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8152.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "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": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 3", "code_information": [ { "code": "8433", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11688.66, "maximum": 12506.87, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "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": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12506.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "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": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC", "code_information": [ { "code": "266", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 57652, "minimum": 7670, "maximum": 104466.4931, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 89388.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 57935.59, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 101980.63, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 80300.91 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 57652.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 70593.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 57367.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 90310.23 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 74948.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 57652.59, "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": 57652.59, "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": 104466.49, "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": 81059.54, "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": 84172.78, "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": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 74948.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 72065.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60207.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 57652.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57652.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 92244.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 74948.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 86478.89, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57652.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 49446.8 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 56799.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 92153.3 } ] } ] }, { "description": "Exc Foot/Toe Tum Dep 1.5Cm/>", "code_information": [ { "code": "28041", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13000, "discounted_cash": 3717, "minimum": 371.56, "maximum": 13000, "payers_information": [ { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 397.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 371.56 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 390.14 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITHOUT CCMCC", "code_information": [ { "code": "446", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7991, "minimum": 6490, "maximum": 16314.356, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11896.47 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8034.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13086.16, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 9164.01 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7991.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9529.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7955.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12019.11 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10389.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7991.89, "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": 7991.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14481.3, "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": 11236.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11668.16, "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": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10389.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9989.86, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8349.34, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7991.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7991.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12787.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10389.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11987.84, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7991.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7884.65 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7876.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12264.4 } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 1", "code_information": [ { "code": "1781", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39720.89, "maximum": 42501.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "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": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42501.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "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": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Shoulder Tum Deep 5 Cm/>", "code_information": [ { "code": "23073", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 3717, "minimum": 568.5, "maximum": 10500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 568.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 596.93 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 608.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 4", "code_information": [ { "code": "3044", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54426.59, "maximum": 58236.45, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "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": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58236.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "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": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "039", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11253, "minimum": 3540, "maximum": 23180.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16983.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11312, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18629.21, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 12756.54 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 11253.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 13540.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11201.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17158.13 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14629.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11253.82, "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": 11253.82, "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": 20391.92, "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": 15822.87, "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": 16430.58, "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": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 14629.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14067.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11755.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11253.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11253.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18006.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14629.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 16880.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11253.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19272.5 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 11090.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17508.3 } ] } ] }, { "description": "Exc skn hdrdnt ax complex", "code_information": [ { "code": "11451", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8150, "discounted_cash": 3717, "minimum": 223.22, "maximum": 8150, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 223.22 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 238.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 8150, "discounted_cash": 3717, "minimum": 223.22, "maximum": 8150, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 223.22 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 234.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 238.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 223.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 3", "code_information": [ { "code": "3033", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 49432.46, "maximum": 52892.73, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "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": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52892.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "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": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 4", "code_information": [ { "code": "0824", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14031.48, "maximum": 15013.68, "payers_information": [ { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "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": 14031.48, "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": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15013.68, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "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": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc tr-ext b9+marg 1.1-2 cm", "code_information": [ { "code": "11402", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250, "discounted_cash": 906, "minimum": 103.06, "maximum": 5250, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.1, "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": 103.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "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": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 108.21 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1014.84, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 515.65 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 860.99, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 5250, "discounted_cash": 906, "minimum": 103.06, "maximum": 5250, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.1, "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": 103.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "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": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 108.21 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1014.84, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 515.65 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 860.99, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES - SOI : 2", "code_information": [ { "code": "0922", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14154.46, "maximum": 15145.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "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": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15145.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "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": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 1", "code_information": [ { "code": "8411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15021.62, "maximum": 16073.13, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "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": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16073.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "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": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DYSEQUILIBRIUM", "code_information": [ { "code": "149", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7282, "minimum": 5605, "maximum": 23312.984, "payers_information": [ { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9467.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10924.1, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7282.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9040.62 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11498.4 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11153.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7321.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12158.78, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8237.12 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7282.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 8657.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7249.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11268.43 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9467.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7282.73, "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": 7282.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13196.31, "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": 10239.52, "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": 10632.79, "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": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 9467.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9103.41, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7608.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7282.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7282.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11652.37, "additional_payer_notes": "160.00% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 4", "code_information": [ { "code": "8414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 173017.86, "maximum": 185129.11, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "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": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 185129.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "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": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "148", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7708, "minimum": 6195, "maximum": 14526.21, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11947.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7749.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14526.21, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 8574.27 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 7708.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 9181.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7674.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12070.37 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10021.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7708.97, "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": 7708.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13968.65, "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": 10838.81, "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": 11255.1, "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": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 10021.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9636.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8053.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7708.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7708.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12334.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10021.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 11563.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7708.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10462.6 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 7598.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12316.7 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 2", "code_information": [ { "code": "5312", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5424.53, "maximum": 5804.25, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "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": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5804.25, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "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": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 1", "code_information": [ { "code": "9111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15548.49, "maximum": 16636.88, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "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": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16636.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "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": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 2", "code_information": [ { "code": "1102", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6936.23, "maximum": 7421.77, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "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": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7421.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "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": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 4", "code_information": [ { "code": "5304", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14427.96, "maximum": 15437.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "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": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15437.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "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": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EX ARMELBOW TUM DEEP < 5 CM", "code_information": [ { "code": "24076", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 3717, "minimum": 483.82, "maximum": 10500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 483.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% 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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1982.46 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield 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 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 517.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 3717, "minimum": 483.82, "maximum": 10500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 483.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% 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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1982.46 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield 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 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 517.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 2", "code_information": [ { "code": "9112", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18876.14, "maximum": 20197.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "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": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20197.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "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": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 3", "code_information": [ { "code": "7593", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13046.65, "maximum": 13959.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "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": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13959.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "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": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 4", "code_information": [ { "code": "5144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28211.38, "maximum": 30186.18, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "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": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30186.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "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": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXC BACK LES SC < 3 CM", "code_information": [ { "code": "21930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5729.16, "discounted_cash": 2113, "minimum": 532.42, "maximum": 5729.16, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 532.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 559.04 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2366.95, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1982.46 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 569.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 532.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 3", "code_information": [ { "code": "9503", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 26055.14, "maximum": 27879, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "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": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27879, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "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": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 4", "code_information": [ { "code": "7594", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 23951.9, "maximum": 25628.53, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "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": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25628.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "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": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Back Les Sc 3 Cm/>", "code_information": [ { "code": "21931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11700, "discounted_cash": 2113, "minimum": 386.08, "maximum": 11700, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 386.08 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 405.38 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2366.95, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 413.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC", "code_information": [ { "code": "982", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23272, "minimum": 12095, "maximum": 42170.6216, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36531.07 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23389.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40589.14, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 27490.89 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 23272.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 28319.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23160.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36907.68 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 30254.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23272.97, "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": 23272.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42170.62, "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": 32721.8, "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": 33978.54, "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": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 30254.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29091.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24306.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23272.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23272.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37236.75, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 30254.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 34909.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23272.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27981.2 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 22930.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37660.9 } ] } ] }, { "description": "Egd Biopsy Single/Multiple", "code_information": [ { "code": "43239", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9176.81, "discounted_cash": 1160, "minimum": 335.91, "maximum": 9176.81, "payers_information": [ { "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": 335.91 }, { "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" }, { "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 352.71 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1299.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 985.13 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% 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 Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net 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": 359.42 }, { "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": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan 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 Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA 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": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1509.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1102.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "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": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 3", "code_information": [ { "code": "7223", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6444.35, "maximum": 6895.45, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "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": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6895.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "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": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Face-Mm B9+Marg 0.6-1 Cm", "code_information": [ { "code": "11441", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15750, "discounted_cash": 906, "minimum": 106.81, "maximum": 15750, "payers_information": [ { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.81 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 106.81 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.81 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 860.99, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.1, "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": 106.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "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": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.15 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1014.84, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 515.65 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC", "code_information": [ { "code": "981", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 44194, "minimum": 25665, "maximum": 80080.4702, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70933 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 44412.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77396.93, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 50764.55 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 44194.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 54044.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 43976.92, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 71664.26 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 57452.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 44194.52, "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": 44194.52, "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": 80080.47, "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": 62137.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 64524, "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": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 57452.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 55243.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46153.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 44194.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 44194.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 70711.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 57452.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 66291.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 44194.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 65895.3 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 43541.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 73126.8 } ] } ] }, { "description": "Egd Control Bleeding Any", "code_information": [ { "code": "43255", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9400, "discounted_cash": 2455, "minimum": 412.81, "maximum": 12096.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3138.25, "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": 412.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2505.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.45 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2750.03, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1475.29 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 412.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3683.91, "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": 2480.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3235.33, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3438.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "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": 2455.94, "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": 3453.05, "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": 3585.67, "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": 441.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3192.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3069.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 412.81 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2603.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 412.81 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 412.81 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3192.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3192.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2333.14, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 412.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3235.33, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Exc face-mm b9+marg 1.1-2 cm", "code_information": [ { "code": "11442", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7300, "discounted_cash": 906, "minimum": 114.81, "maximum": 7300, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.1, "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": 114.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "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": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1014.84, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 964.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 860.99, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 7300, "discounted_cash": 906, "minimum": 114.81, "maximum": 7300, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1178.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 860.99, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.1, "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": 114.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "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": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.55 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1014.84, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 964.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 3", "code_information": [ { "code": "7923", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22449.74, "maximum": 24021.22, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "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": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24021.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "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": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 3", "code_information": [ { "code": "3243", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19651.07, "maximum": 21026.64, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "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": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21026.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "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": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 3", "code_information": [ { "code": "3143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15322.69, "maximum": 16395.28, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "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": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16395.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "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": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Foot/Toe Tum Sc < 1.5 Cm", "code_information": [ { "code": "28043", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13000, "discounted_cash": 2113, "minimum": 433.1, "maximum": 13000, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 433.1 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.76 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2366.95, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1982.46 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 463.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 433.1 } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 2", "code_information": [ { "code": "8432", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5940.8, "maximum": 6356.66, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "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": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6356.66, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "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": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 1", "code_information": [ { "code": "3261", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12205.99, "maximum": 13060.41, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "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": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13060.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "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": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT PROCEDURES WITH CC", "code_information": [ { "code": "504", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17752, "minimum": 11800, "maximum": 36860.624, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26186.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17842.15, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28198.52, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 19580.77 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 17752.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 21531.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17667.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26456.28 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23078.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17752.41, "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": 17752.41, "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": 32167.37, "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": 24959.89, "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": 25918.52, "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": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "case rate", "standard_charge_dollar": 23078.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22190.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18541.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17752.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17752.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28403.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23078.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "case rate", "standard_charge_dollar": 26628.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17752.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22406.1 }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "case rate", "standard_charge_dollar": 17492.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26996.2 } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 1.1-2", "code_information": [ { "code": "11422", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11375, "discounted_cash": 2113, "minimum": 106.27, "maximum": 11375, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 106.27 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2366.95, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 964.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 113.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 11375, "discounted_cash": 2113, "minimum": 106.27, "maximum": 11375, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.08, "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": 106.27 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.58 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2366.95, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 964.52 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 113.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2747.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.27 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 4", "code_information": [ { "code": "8434", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16967.96, "maximum": 18155.72, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "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": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18155.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "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": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOSCOPY MAXILLARY SINUS", "code_information": [ { "code": "31267", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5798.77, "discounted_cash": 9032, "minimum": 372.21, "maximum": 5798.77, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "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": 372.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "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": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 390.82 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3545.93 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 372.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "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": 5798.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "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": 5798.77, "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 $6490", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 443.98, "10th_percentile": 443.98, "90th_percentile": 443.98, "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": 5798.77, "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": 5798.77, "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": 398.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 372.21 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 372.21 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 372.21 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 372.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5798.77, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 3", "code_information": [ { "code": "3403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7442.96, "maximum": 7963.97, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "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": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7963.97, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "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": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Exc Neck Les Sc 3 Cm/>", "code_information": [ { "code": "21552", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11262.5, "discounted_cash": 3717, "minimum": 370.07, "maximum": 11262.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.46, "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": 370.07 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "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": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.57 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4162.81, "additional_payer_notes": "111.97% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2712.03 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 395.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Inc", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L A Care Health Plan Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Duals Cal MediConnect", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "LA Care Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Optum Health Plan", "plan_name": "Optum Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Patient Choice Health Plan", "plan_name": "Patient Choice Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4832.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Primecare Medical Network", "plan_name": "Primecare Medical Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 370.07 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "UHC", "plan_name": "UHC Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 3", "code_information": [ { "code": "1783", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 53704.67, "maximum": 57464, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "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": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57464, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Heritage Provider Network Inc", "plan_name": "Heritage Provider Network Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "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": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina Healthcare", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC", "code_information": [ { "code": "267", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 44840, "minimum": 3835, "maximum": 135632.188, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70198.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 45061.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medicare", "methodology": "case rate", "standard_charge_dollar": 44178.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 79679.46, "additional_payer_notes": "82.45% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Sheild Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44178.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Exchange", "methodology": "case rate", "standard_charge_dollar": 63998.07 }, { "payer_name": "Blue Shield of CA", "plan_name": "Blue Shield Of CA Triwest", "methodology": "case rate", "standard_charge_dollar": 44840.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-26)", "methodology": "case rate", "standard_charge_dollar": 54839.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 44620.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 70922.5 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44178.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44178.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 44178.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 58293.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Excel Inc", "plan_name": "Health Excel Inc Medicare", "methodology": "case rate", "standard_charge_dollar": 44178.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 44840.91, "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": 44840.91, "additional_payer_notes": "100.00% of Medicare Rates"