{ "hospital_name": "Sherman Oaks Hospital", "last_updated_on": "2026-09-01", "version": "3.0", "location_name": [ "Sherman Oaks Hospital" ], "hospital_address": [ "4929 Van Nuys Boulevard Sherman Oaks, CA 91403" ], "license_information": { "license_number": "930000149", "state": "CA" }, "attestation": { "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "EM V. Garcia" }, "type_2_npi": [ "1750491247", "1922263797" ], "standard_charge_information": [ { "description": "*AFB CULTURE", "code_information": [ { "code": "87116", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17, "discounted_cash": 10, "minimum": 4.002, "maximum": 30.41, "payers_information": [ { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.31, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.58 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.31, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 15.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.7, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.96, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.83, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.57, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "*FUNGAL CULTURE SKIN,HAIR,NAIL", "code_information": [ { "code": "87101", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10, "discounted_cash": 7, "minimum": 2.892, "maximum": 48.67, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "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": 7.86 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.98 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "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": 7.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.79, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "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": 7.71, "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": 10 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 7.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.07, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.86 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.86 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.16, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.86 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.79, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "*FUNGAL CULTURE BLOOD", "code_information": [ { "code": "87103", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10, "discounted_cash": 20, "minimum": 3, "maximum": 10, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "*AFB SMEAR", "code_information": [ { "code": "87206", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11, "discounted_cash": 5, "minimum": 2.163, "maximum": 48.67, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "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": 5.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.13 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "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": 5.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.34, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.35, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.4, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "*FUNGAL SMEAR WET MOUNT", "code_information": [ { "code": "87210", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27, "discounted_cash": 5, "minimum": 4.09, "maximum": 53, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.84, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.09 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.91, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.44, "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": 4.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.94, "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": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.53 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "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": 4.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "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": 5.82, "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": 8.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.09 } ] } ] }, { "description": "*KOH PREP", "code_information": [ { "code": "87220", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9, "discounted_cash": 4, "minimum": 2.7, "maximum": 53, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.28 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.2 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.28 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.87, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.28 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.28 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.07, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.28 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.87, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "18-HYDROXYCORTICOSTERONE, S", "code_information": [ { "code": "82542", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 116.98, "discounted_cash": 24, "minimum": 2.91, "maximum": 131.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.57, "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": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 25.55 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "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": 17.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.46, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 33.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 33.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 35.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.33, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 37.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.91, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.62, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.46, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "2-D ECHOCARDIOGRAM", "code_information": [ { "code": "93307", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2000, "discounted_cash": 305, "minimum": 24.6, "maximum": 2000, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 226.07 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 308.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 348.13, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 429.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 445.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 359.13, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 473.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 366.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 362.79, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 348.13, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "17-OH PROGESTERONE LCMS (#0700", "code_information": [ { "code": "83498", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10, "discounted_cash": 27, "minimum": 3, "maximum": 10, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "11-DEOXYCORTISOL", "code_information": [ { "code": "82634", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.14, "discounted_cash": 29, "minimum": 10.842, "maximum": 36.14, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.14, "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": 29.86 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 36.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.38, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 36.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 36.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.43, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 36.14, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.78, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.38, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "17-HYDROXYPREGN", "code_information": [ { "code": "84143", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.16, "discounted_cash": 22, "minimum": 8.448, "maximum": 28.16, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.16 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "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": 23.27 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 28.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "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": 22.81, "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": 28.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.82, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.1, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "24 HOUR HOLTER MONITOR", "code_information": [ { "code": "93225", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1168, "discounted_cash": 170, "minimum": 42.77, "maximum": 1168, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 44.91 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "25 HYDROXYVIT D LCMS D2+D3 LC", "code_information": [ { "code": "82306", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28, "discounted_cash": 29, "minimum": 3.126, "maximum": 93.5, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.03 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 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": 28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "24 HR HOLTER W SI; RECORDING", "code_information": [ { "code": "93225", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 358, "discounted_cash": 170, "minimum": 42.77, "maximum": 1168, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 44.91 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.77 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "5-HIAA 24HR UR LC", "code_information": [ { "code": "83497", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.33, "discounted_cash": 12, "minimum": 2.499, "maximum": 71.5, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "5-HIAA Qn,Random Urine", "code_information": [ { "code": "83497", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.92, "discounted_cash": 12, "minimum": 2.499, "maximum": 71.5, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.17, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.33, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "5' NUCLEOTIDASE", "code_information": [ { "code": "83915", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.89, "discounted_cash": 11, "minimum": 1.467, "maximum": 4.89, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "A-SUBUNIT, FREE LC 140269", "code_information": [ { "code": "83520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 52.94, "discounted_cash": 17, "minimum": 3.942, "maximum": 690, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.69, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.31, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.72, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.69, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "A. RIGHT IUC-ILIAC LTD", "code_information": [ { "code": "93979", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 702, "discounted_cash": 133, "minimum": 96.72, "maximum": 702, "payers_information": [ { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 119.48 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" } ] } ] }, { "description": "A-V SHUNT ANGIOGRAM", "code_information": [ { "code": "36901", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2978, "discounted_cash": 2014, "minimum": 106.95, "maximum": 4312.55, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2654.07, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2574.44, "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": 518.24 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2054.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2345.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 544.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "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": 518.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2978, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2034.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2296.76, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2820.58, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2832.67, "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": 2941.46, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.52 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 518.24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2369.29, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 518.24 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 518.24 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2345.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2978, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2345.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2417.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2393.46, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2345.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 518.24 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2014.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2654.07, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2296.76, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "A4I RBC AG NEG 1 PER UNIT", "code_information": [ { "code": "86902", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900, "discounted_cash": 458, "minimum": 2.62, "maximum": 900, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 467.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 534, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "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": 2.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 688.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 463.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 522.99, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 642.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 645.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.79, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 539.5, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 534, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 711.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 534, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 550.51, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 545.01, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 534, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 522.99, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "5-HIAA PLASMA LC", "code_information": [ { "code": "83497", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71.5, "discounted_cash": 12, "minimum": 2.499, "maximum": 71.5, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.48, "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": 13.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.05 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "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": 13.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.17, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.33, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.71, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABD-4 VIEWS", "code_information": [ { "code": "74021", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 477, "discounted_cash": 133, "minimum": 25.06, "maximum": 562.55, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 48.27 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 286.91, "10th_percentile": 286.91, "90th_percentile": 286.91, "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": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% 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": 9733, "minimum": 7796.8223, "maximum": 18407.4505, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18407.45 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11329.47, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9927.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11329.47, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9830.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11095.87, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12653.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9733.22, "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": 9733.22, "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": 17636.59, "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": 13684.91, "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": 14210.5, "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": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11446.27, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11329.47, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 15086.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15573.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11329.47, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11679.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11563.07, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11329.47, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10254.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9733.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18407.45 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11095.87, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABD-FLAT&UPRTORDECUB", "code_information": [ { "code": "74021", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 562.55, "discounted_cash": 133, "minimum": 25.06, "maximum": 562.55, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 48.27 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 286.91, "10th_percentile": 286.91, "90th_percentile": 286.91, "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": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMEN (ACUTE OR COMPLETE)", "code_information": [ { "code": "74022", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 562.55, "discounted_cash": 133, "minimum": 36.75, "maximum": 562.55, "payers_information": [ { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 69.04 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 3", "code_information": [ { "code": "2513", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6680.75, "maximum": 7148.4, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABI ANKLE/BRACHIAL PRESURE*UNI", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 608.55, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABL KINASE DOMAIN MUTATION ANL", "code_information": [ { "code": "81170", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 447.98, "discounted_cash": 300, "minimum": 134.394, "maximum": 447.98, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 395.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383.35, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 306, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 349.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 252 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 447.98, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 342, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 420, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 421.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 438 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 352.8, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 349.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 447.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 349.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 360, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 356.4, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 349.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 395.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 342, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACETAMINOPHEN - 80143 - 80101", "code_information": [ { "code": "80143", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 69, "discounted_cash": 18, "minimum": 1.875, "maximum": 93.2, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.92, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.14, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.25, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "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" } ] } ] }, { "description": "ACETAMINOPHEN - 80143 - 890021", "code_information": [ { "code": "80143", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.2, "discounted_cash": 18, "minimum": 1.875, "maximum": 93.2, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.92, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.14, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "A LEFT IUC-ILIAC LTD", "code_information": [ { "code": "93979", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 702, "discounted_cash": 133, "minimum": 96.72, "maximum": 702, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 119.48 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 2", "code_information": [ { "code": "5432", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5975.15, "maximum": 6393.41, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Achr Binding ABS, Serum*LC", "code_information": [ { "code": "83519", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26.75, "discounted_cash": 18, "minimum": 7.464, "maximum": 315, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.51, "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": 14.08 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.77, "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": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.7 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "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": 14.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.75, "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": 18.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.98, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.64, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.08 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.86, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.98, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "A1-ANTITRYPSIN SERUM LC", "code_information": [ { "code": "82103", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.44, "discounted_cash": 13, "minimum": 1.578, "maximum": 61.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 4", "code_information": [ { "code": "5434", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17669.85, "maximum": 18906.74, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACID PHOSPHATASE PROST", "code_information": [ { "code": "80307", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59, "discounted_cash": 62, "minimum": 2.7, "maximum": 359.15, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 45.68 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 59, "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": 43.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 105.04, "10th_percentile": 105.04, "90th_percentile": 105.04, "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": 59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.55 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABCESS LOCALIZATION", "code_information": [ { "code": "76882", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 560.4, "discounted_cash": 133, "minimum": 8.66, "maximum": 702, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 27.56 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABORTION WITHOUT D&C", "code_information": [ { "code": "779", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8199, "minimum": 5510.26, "maximum": 29237.7859, "payers_information": [ { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9544.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9839.82, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9741.42, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9544.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5510.26 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15991.9 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9347.83, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15991.9 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9544.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8363.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9544.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8281.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9347.83, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10659.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8199.85, "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": 8199.85, "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": 14858.13, "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": 11528.99, "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": 11971.78, "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": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9643.02, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8199.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9544.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 12709.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13119.76, "additional_payer_notes": "160.00% of Medicare Rates" } ] } ] }, { "description": "ABDOMINAL AORTOGRAM", "code_information": [ { "code": "75625", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9197, "discounted_cash": 4041, "minimum": 102.25, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "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": 102.25 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 389.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 102.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4606.9, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 109.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4752.38, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4849.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4800.87, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4606.9, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 3", "code_information": [ { "code": "5643", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6403.11, "maximum": 6851.33, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACOUS ELECTR CARDGRAPHY SINGLE", "code_information": [ { "code": "93799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 152.75, "discounted_cash": 164, "minimum": 45.825, "maximum": 196.6, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACTH PLASMA/LC", "code_information": [ { "code": "82024", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.31, "discounted_cash": 38, "minimum": 6.993, "maximum": 47.68, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "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": 23.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "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": 23.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "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": 23.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "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": 23.31, "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": 23.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABI", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 468, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" } ] } ] }, { "description": "ACUSCOPE/ELEC STIM ATT 15 MIN", "code_information": [ { "code": "97032", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130, "discounted_cash": 16, "minimum": 12.42, "maximum": 192.05, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.48, "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": 12.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.04 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "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": 12.42 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.05, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.27, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 22.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.54 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.85, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.42 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 24.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.24, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.27, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABI ANKLE/BRACHIAL PRESURE*BIL", "code_information": [ { "code": "93923", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 744.15, "discounted_cash": 276, "minimum": 96.36, "maximum": 1352, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.36 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 281.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.67, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 146.63 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.36 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 414.53, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 279.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.04, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 386.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 388.55, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 403.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 96.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 324.99, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.36 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.67, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 428.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.67, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 331.62, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.3, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.67, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.04, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AB ID/EACH PANEL & MEDIA", "code_information": [ { "code": "86870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 89, "discounted_cash": 458, "minimum": 18.96, "maximum": 600, "payers_information": [ { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.61 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 1", "code_information": [ { "code": "1931", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8140.51, "maximum": 8710.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABI* ANKLE/BRACHIAL PRESSURES", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 468, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABD PARACENTESIS W/O IMG GUIDE", "code_information": [ { "code": "49082", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2153.15, "discounted_cash": 1160, "minimum": 58.45, "maximum": 2153.15, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 1483.32, "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": 58.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1351.18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1323.32, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1632.1, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1694.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.54 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1365.11, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1351.18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1799.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1351.18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1392.97, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1379.04, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1351.18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1323.32, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACETONE URINE/SERUM", "code_information": [ { "code": "82010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59, "discounted_cash": 8, "minimum": 8.17, "maximum": 71, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.13 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.26, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.31, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.61, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.31, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 3", "code_information": [ { "code": "1933", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13200.37, "maximum": 14124.4, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABLATION SUPRAVENTACHY", "code_information": [ { "code": "93653", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13191.6, "discounted_cash": 33452, "minimum": 659.46, "maximum": 13191.6, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 659.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1408.46 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "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": 659.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 705.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 659.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 659.46 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 659.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 659.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13191.6, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABDCXRFB(XR ABD/CH FB)", "code_information": [ { "code": "76010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 371.8, "discounted_cash": 111, "minimum": 22.43, "maximum": 371.8, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 39.81 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Acetylcholine Rcptr AB,ALL*LC1", "code_information": [ { "code": "84238", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 135.9, "discounted_cash": 36, "minimum": 36.57, "maximum": 385, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.3, "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": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 52.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "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": 37.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 54.86, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.69, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 51.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 51.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 53.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 37.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 43.01, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.29 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.29 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 56.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 43.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 43.45, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.29 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.69, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CCMCC", "code_information": [ { "code": "290", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9039, "minimum": 9039.69, "maximum": 16748.0428, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13197.95, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10630.68, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10522.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14011.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14463.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10522.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10847.63, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10739.15, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10522.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13054.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16748.04 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10305.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16748.04 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10522.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9220.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10522.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9130.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10305.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9039.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11751.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9039.69, "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": 9039.69, "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": 16379.92, "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": 12709.8, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "ABO TYPE", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.55, "discounted_cash": 170, "minimum": 2.73, "maximum": 129, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABDOMEN (KUB)", "code_information": [ { "code": "74018", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "discounted_cash": 111, "minimum": 16.73, "maximum": 600, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.06 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACHR Binding Abs, Serum", "code_information": [ { "code": "86041", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.33, "discounted_cash": 18, "minimum": 9.099, "maximum": 30.33, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.51, "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": 18.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.77, "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": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "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": 18.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.98, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.64, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 28.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.86, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.98, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMEN COMPLETE ULTRASOUND", "code_information": [ { "code": "76700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1040, "discounted_cash": 133, "minimum": 82.35, "maximum": 1040, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.35 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 125.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 530.41, "10th_percentile": 530.41, "90th_percentile": 530.41, "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": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 88.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 82.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.35 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Achr Blocking ABS, Serum*LC", "code_information": [ { "code": "83519", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.88, "discounted_cash": 18, "minimum": 7.464, "maximum": 315, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.51, "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": 14.08 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.77, "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": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.7 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "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": 14.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.98, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.64, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.08 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.86, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.98, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL AORTA ULTRASOUND", "code_information": [ { "code": "76770", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 637, "discounted_cash": 133, "minimum": 79.89, "maximum": 740, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 121.57 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 85.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 79.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare 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": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "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" } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACP 600 CC PLASMA", "code_information": [ { "code": "P9017", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 303, "discounted_cash": 85, "minimum": 30.99, "maximum": 303, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 112.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 109.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 87.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 70.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "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": 67.03 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 128.34, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 97.54, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 119.78, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 120.3, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 124.92, "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": 71.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 100.62, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 132.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 102.67, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 101.65, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 112.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 97.54, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACTIVITY THERAPY", "code_information": [ { "code": "G0176", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 785, "minimum": 35, "maximum": 785, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 84.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABO AND RH", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 129, "discounted_cash": 170, "minimum": 2.73, "maximum": 129, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 129, "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": 2.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 129, "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": 129, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 4", "code_information": [ { "code": "1934", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18754.23, "maximum": 20067.03, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "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" } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACP 400 CC PLASMA", "code_information": [ { "code": "P9017", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 149, "discounted_cash": 85, "minimum": 30.99, "maximum": 303, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 112.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 109.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 87.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 70.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "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": 67.03 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 128.34, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 97.54, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 119.78, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 120.3, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 124.92, "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": 71.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 100.62, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 132.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 102.67, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 101.65, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.03 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 85.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 112.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 97.54, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 2", "code_information": [ { "code": "5642", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3745.55, "maximum": 4007.74, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC", "code_information": [ { "code": "280", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15446, "minimum": 10945.5619, "maximum": 28079.92, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28079.92 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17980.06, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15755.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 15446.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17980.06, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15446.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15601.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17609.34, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20080.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15446.79, "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": 15446.79, "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": 27989.58, "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": 21718.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22552.31, "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": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18165.43, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15446.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15446.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17980.06, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 23942.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24714.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17980.06, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18536.15, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18350.79, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17980.06, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18300.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15446.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28079.92 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17609.34, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACROMIO LEFT CLAVICULAR JOINT", "code_information": [ { "code": "73050", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 239, "discounted_cash": 111, "minimum": 26.75, "maximum": 239, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 45.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ABSCDRNPER", "code_information": [ { "code": "75989", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1302, "minimum": 80.96, "maximum": 2022, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.96 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 236.18 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.96 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 80.96 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.96 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.96 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.96 } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE VIRAL HEP (HAV,HBV,HCV)", "code_information": [ { "code": "80074", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142.89, "discounted_cash": 47, "minimum": 5.712, "maximum": 142.89, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 60.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.58, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 66.09 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "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": 40 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.45, "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": 48.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.3, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "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": 47.63, "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": 66.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.54 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.01, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 73.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 57.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.58, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.3, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACROMIO RIGHT CLAVICULAR JOINT", "code_information": [ { "code": "73050", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 239, "discounted_cash": 111, "minimum": 26.75, "maximum": 239, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 45.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 3", "code_information": [ { "code": "4693", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8886.82, "maximum": 9508.9, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACROMIO-CLAVICULAR JOINTS", "code_information": [ { "code": "73050", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 239, "discounted_cash": 111, "minimum": 26.75, "maximum": 239, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 45.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACHR-modulating Ab", "code_information": [ { "code": "86043", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.33, "discounted_cash": 12, "minimum": 9.099, "maximum": 30.33, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.17, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC", "code_information": [ { "code": "835", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20023, "minimum": 14523.0255, "maximum": 36539.4735, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36539.47 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23306.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20423.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 20023.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20023.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23306.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20023.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20223.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22826.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20023.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 26030.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20023.15, "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": 20023.15, "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": 36281.95, "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": 28152.55, "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": 29233.8, "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": 20023.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23547.22, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20023.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20023.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20023.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20023.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20023.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20023.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23306.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 31035.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32037.04, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23306.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24027.78, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23787.5, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20023.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23306.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20023.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24241.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20023.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36539.47 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22826.39, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "836", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11792, "minimum": 11792.9, "maximum": 57214.4087, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21738.24 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13726.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12028.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 11792.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13726.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11792.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11910.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13443.93, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 15330.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11792.92, "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": 11792.92, "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": 21368.77, "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": 16580.85, "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": 17217.66, "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": 11792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13868.47, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11792.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11792.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13726.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 18279.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18868.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13726.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14151.5, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14009.99, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13726.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11792.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16944 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11792.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21738.24 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13443.93, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 4", "code_information": [ { "code": "7554", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8638.75, "maximum": 9243.46, "payers_information": [ { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC", "code_information": [ { "code": "834", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 52363, "minimum": 24839.7922, "maximum": 109395, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 94557.16 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60951.23, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 53410.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60951.23, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 52887.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59694.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 68072.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 52363.6, "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": 52363.6, "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": 94882.84, "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": 73623.22, "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": 76450.86, "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": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61579.59, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60951.23, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 81163.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 83781.76, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60951.23, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62836.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62207.96, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60951.23, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 109395 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52363.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 94557.16 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59694.5, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITHOUT CCMCC", "code_information": [ { "code": "122", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7672, "minimum": 3719.15, "maximum": 13902.715, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11603.88 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8930.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7826.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8930.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7749.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8746.74, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9974.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7672.58, "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": 7672.58, "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": 13902.71, "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": 10787.65, "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": 11201.97, "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": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9022.95, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8930.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 11892.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12276.13, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8930.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9207.1, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9115.03, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8930.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 3719.15 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7672.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11603.88 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8746.74, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADL TRAINING EA 15 MIN", "code_information": [ { "code": "97535", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "discounted_cash": 36, "minimum": 5.31, "maximum": 317.95, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.03, "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": 5.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.58 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "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": 5.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 54.03, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.06, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 50.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 50.64 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 52.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.36, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.31 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 55.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 43.22, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.79, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.06, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITH CCMCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11258, "minimum": 5799.77, "maximum": 20401.2899, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11258.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5799.77 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11259, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19899.21 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12835.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19899.21 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13105.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11484.18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 11258.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11259, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13105.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11258.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11371.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12835.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11259, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14636.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11258.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11258.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20401.29, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 15830.14, "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": 16438.13, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11259, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13240.57, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11259, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11258.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11259, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11259, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11258.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11259, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13105.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17451.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18014.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13105.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13510.79, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13375.68, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11259, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13105.46, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ACOUS ELECTR CARD MULTI AV+VV", "code_information": [ { "code": "93799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196.6, "discounted_cash": 164, "minimum": 45.825, "maximum": 196.6, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 167.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 166.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 187.74, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 193.66, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 195.64, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 187.74, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CCMCC", "code_information": [ { "code": "282", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7076, "minimum": 7076.9, "maximum": 23589.3472, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12404.5 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8237.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7218.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8237.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7147.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8067.67, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9199.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12823.34, "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": 9950.12, "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": 10332.27, "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": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8322.43, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8237.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10969.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11323.04, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8237.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8492.28, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8407.36, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8237.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11066.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7076.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12404.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8067.67, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADMIN INFLUENZA VIRUS VAC", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 154.35, "discounted_cash": 59, "minimum": 25, "maximum": 154.35, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 61.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 69.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 68.31, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 84.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 87.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 70.47, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 69.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 92.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 69.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 71.9, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 71.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 69.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 68.31, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC", "code_information": [ { "code": "281", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8938, "minimum": 8611.3979, "maximum": 16197.4318, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15769.51 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10404.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9117.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10404.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9028.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10190.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11620.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8938.98, "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": 8938.98, "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": 16197.43, "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": 12568.21, "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": 13050.91, "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": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10512.24, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10404.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13855.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14302.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10404.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10726.78, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10619.51, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10404.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12337.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8938.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15769.51 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10190.44, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACOUS ELECTR CARD MULTI AV/VV", "code_information": [ { "code": "93799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196.6, "discounted_cash": 164, "minimum": 45.825, "maximum": 196.6, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 167.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 166.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 187.74, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 193.66, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 195.64, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 196.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 187.74, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADMIN PNEUMOCOCCAL VACCINE", "code_information": [ { "code": "G0009", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 154.35, "discounted_cash": 59, "minimum": 39.6, "maximum": 154.35, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 61.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 69.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 68.31, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 84.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 87.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 70.47, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 69.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 92.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 69.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 71.9, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 71.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 69.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 68.31, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADRENA LEFT ANGIO", "code_information": [ { "code": "75731", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2260, "discounted_cash": 4041, "minimum": 136.04, "maximum": 2260, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2260, "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": 136.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2260, "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": 2260, "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": 145.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADDL VES STNT TIBIAL/PERONEAL", "code_information": [ { "code": "37234", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21184.9, "minimum": 247.464, "maximum": 21184.9, "payers_information": [ { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 247.46 } ] } ] }, { "description": "ADRENA RIGHT ANGIO", "code_information": [ { "code": "75731", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2260, "discounted_cash": 4041, "minimum": 136.04, "maximum": 2260, "payers_information": [ { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2260, "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": 136.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2260, "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": 2260, "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": 145.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ACTIVATED CLOTTING TIME (i-STA", "code_information": [ { "code": "85347", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.4, "discounted_cash": 4, "minimum": 4.19, "maximum": 21.4, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.98, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.51 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.99, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.02 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.03, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.98, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.98, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.98, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADDL VES STNT/ATHEREC TIB/PERO", "code_information": [ { "code": "37235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21184.9, "minimum": 351.225, "maximum": 21184.9, "payers_information": [ { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 351.23 } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "615", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13501, "minimum": 13501.1, "maximum": 41531.4466, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24514.76 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15715.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13771.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15715.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13636.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15391.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17551.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13501.1, "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": 13501.1, "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": 24463.99, "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": 18982.55, "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": 19711.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15877.29, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15715.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 20926.71, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21601.76, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15715.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16201.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16039.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15715.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19805.5 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13501.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24514.76 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15391.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADJ TISSUE TRSF, 10SQCM/LESS", "code_information": [ { "code": "14060", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6597, "discounted_cash": 2640, "minimum": 605.06, "maximum": 6597, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 3374.39, "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": 605.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 635.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3712.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3855.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 647.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3105.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4093.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3168.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3137.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADENO 20MG CARDIAC STRESS", "code_information": [ { "code": "78452", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2163, "discounted_cash": 1656, "minimum": 295.9, "maximum": 5284, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 316.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 295.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1948.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.9 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1928.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1928.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1988.36, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1968.48, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1928.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 295.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1888.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2117.32, "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": 295.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1690.11, "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": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1928.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 365.53 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "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": 295.9 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1673.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1888.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "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": 1656.97, "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": 2163, "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": 2163, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "ADRENAL IMAGING 48 HOUR", "code_information": [ { "code": "78075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1082, "discounted_cash": 1656, "minimum": 290.57, "maximum": 2163, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 328.06 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1082, "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": 290.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1082, "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": 1082, "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": 310.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 290.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.57 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1082, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADJ TISSUE TRSF,10SQCM/LESS", "code_information": [ { "code": "14040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4894, "discounted_cash": 2640, "minimum": 483.82, "maximum": 4894, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 3374.39, "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": 483.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 508.01 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3712.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3855.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 517.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3105.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4093.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3168.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3137.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 2", "code_information": [ { "code": "1932", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9819.71, "maximum": 10507.09, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADENOVIRUS DFA", "code_information": [ { "code": "87260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.8, "discounted_cash": 14, "minimum": 2.826, "maximum": 14.8, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "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": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "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": 11.59 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.8, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 2", "code_information": [ { "code": "4012", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13076.33, "maximum": 13991.67, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION", "code_information": [ { "code": "880", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9329, "minimum": 5936, "maximum": 16904.9634, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16399.05 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10859.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9516.04, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10859.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9422.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10635.57, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12128.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9329.45, "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": 9329.45, "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": 16904.96, "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": 13117.21, "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": 13621, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10971.43, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10859.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 14460.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14927.12, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10859.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11195.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11083.39, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10859.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7891.19 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16399.05 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10635.57, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADJ TISSUE TRSF,10.1-30SQ CM - 14061 - 02698", "code_information": [ { "code": "14061", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4894, "discounted_cash": 2640, "minimum": 1062.72, "maximum": 4894, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 3374.39, "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": 1062.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1115.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3712.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3855.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1137.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3105.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4093.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3168.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3137.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADRENALIN SYNRINGE", "drug_information": { "unit": 10, "type": "ML" }, "code_information": [ { "code": "00409492134", "type": "NDC" }, { "code": "J0171", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 40.4, "median_amount": 19.91, "10th_percentile": 19.91, "90th_percentile": 19.91, "count": "1 through 10" } ] } ] }, { "description": "ADRENAL ANGIOGRAM 1 SIDE", "code_information": [ { "code": "75731", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2260, "discounted_cash": 4041, "minimum": 136.04, "maximum": 2260, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2260, "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": 136.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2260, "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": 2260, "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": 145.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2260, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH CC", "code_information": [ { "code": "289", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16423, "minimum": 9251.03, "maximum": 29759.2552, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 16423.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16423.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19116.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16423.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16587.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18722.71, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16423.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 21350.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16423.43, "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": 16423.43, "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": 29759.26, "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": 23091.34, "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": 23978.21, "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": 16423.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19313.95, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16423.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16423.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16423.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16423.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16423.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16423.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19116.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 25456.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26277.49, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19116.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19708.12, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19511.03, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16423.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19116.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16423.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9251.03 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16423.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26973.07 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18722.71, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26973.07 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19116.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16751.87, "additional_payer_notes": "102.00% of Medicare Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 2", "code_information": [ { "code": "7552", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2936.48, "maximum": 3142.03, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AEROBIC ID", "code_information": [ { "code": "87077", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160, "discounted_cash": 8, "minimum": 3.666, "maximum": 160, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.21, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 81.61, "10th_percentile": 81.61, "90th_percentile": 81.61, "count": "1 through 10" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.5, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.21, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 1", "code_information": [ { "code": "4011", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10090.03, "maximum": 10796.33, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC", "code_information": [ { "code": "288", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25917, "minimum": 20327.4721, "maximum": 46962.0026, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46728.58 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30167.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 26435.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 25917.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30167.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 25917.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 26176.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29545.63, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 25917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 33692.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 25917.22, "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": 25917.22, "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": 46962, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 36439.61, "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": 37839.14, "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": 25917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30478.65, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25917.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 25917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25917.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30167.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 40171.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 41467.55, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30167.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31100.66, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30789.66, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30167.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25917.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35918.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46728.58 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29545.63, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AEROSOL CHECK", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1322.25, "discounted_cash": 280, "minimum": 16.78, "maximum": 1322.25, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 409.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 329.59, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 434.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 336.31, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 332.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 319.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 420.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 283.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 319.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 394.05, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "ADRENAL SCAN", "code_information": [ { "code": "78075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2163, "discounted_cash": 1656, "minimum": 290.57, "maximum": 2163, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2117.32, "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": 290.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1690.11, "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": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1928.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 328.06 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "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": 290.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1673.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1888.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "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": 1656.97, "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": 2163, "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": 2163, "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": 310.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 290.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1948.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.57 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1928.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1928.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1988.36, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1968.48, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1928.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1656.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2163, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1888.95, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AEROSOL MULTIPLE VIEWS", "code_information": [ { "code": "78598", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1082, "discounted_cash": 694, "minimum": 238.74, "maximum": 1082, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 915.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 887.99, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 238.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 708.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 808.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 284.87 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "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": 238.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1042.38, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 701.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 792.21, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 972.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 977.06, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1014.58, "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": 255.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 238.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 817.23, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 238.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 238.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 808.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1077.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 808.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 833.9, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 825.56, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 808.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 238.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 694.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 915.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 792.21, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AFB ID BY SEQUENCING LC", "code_information": [ { "code": "87153", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 250, "discounted_cash": 115, "minimum": 75, "maximum": 250, "payers_information": [ { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 138.43, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 137.05, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 134.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 151.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 131.51, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 151.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 147.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 117.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 134.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 107.67 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 173.04, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 131.51, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 162.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 168.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135.66, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 134.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 178.81, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 134.28, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ADRENALIN 1 MG AMP", "drug_information": { "unit": 1, "type": "ML" }, "code_information": [ { "code": "00409724101", "type": "NDC" }, { "code": "J0171", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 40.4, "median_amount": 19.91, "10th_percentile": 19.91, "90th_percentile": 19.91, "count": "1 through 10" } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFB MIC PANEL/FOCUS", "code_information": [ { "code": "87188", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "discounted_cash": 6, "minimum": 6.64, "maximum": 180, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.48, "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": 6.77 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.77, "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": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.97 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "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": 6.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.96, "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": 6.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.57, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.81, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.57, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AEROBIC CULTURE LC", "code_information": [ { "code": "87070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.86, "discounted_cash": 8, "minimum": 2.697, "maximum": 134, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.83, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 61.72, "10th_percentile": 61.72, "90th_percentile": 61.72, "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": 12.12 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.24, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.83, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFP TUMOR MARKER*LC", "code_information": [ { "code": "82105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.29, "discounted_cash": 16, "minimum": 2.187, "maximum": 20.71, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AFB,MTB COMPLEX PCR", "code_information": [ { "code": "87556", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 193, "discounted_cash": 41, "minimum": 24.972, "maximum": 193, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.91, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.52, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 46.94 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "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": 38.26 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 62.52, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.52, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 58.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 58.6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 60.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 38.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.02, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.26 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.52, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 64.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.52, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.52, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.52, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.91, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.52, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AEROBIC IDENTIFICATION LC", "code_information": [ { "code": "87077", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.22, "discounted_cash": 8, "minimum": 3.666, "maximum": 160, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.21, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 81.61, "10th_percentile": 81.61, "90th_percentile": 81.61, "count": "1 through 10" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.5, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.22, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.21, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 2", "code_information": [ { "code": "4692", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5463.76, "maximum": 5846.22, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AGENT NOS ASSAY W/OPTIC", "code_information": [ { "code": "87899", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.07, "discounted_cash": 16, "minimum": 2.484, "maximum": 92, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "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": 5.59 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AFTERCARE WITH CCMCC", "code_information": [ { "code": "949", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11509, "minimum": 7475.2793, "maximum": 29633.1, "payers_information": [ { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11509.8, "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": 11509.8, "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": 20855.76, "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": 16182.78, "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": 16804.31, "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": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13535.52, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13397.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17840.19, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18415.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13397.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13811.76, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13673.64, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13397.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29633.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18458.77 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13121.17, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18458.77 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13397.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11740, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13397.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11624.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13121.17, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11509.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14962.74, "additional_payer_notes": "130.00% of Medicare Rates" } ] } ] }, { "description": "AEROSOL LUNG SCAN", "code_information": [ { "code": "78579", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1082, "discounted_cash": 511, "minimum": 138.97, "maximum": 1724, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 674.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.97 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 521.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 595.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 165.84 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 767.48, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 516.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 583.28, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 716.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 719.38, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 747.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 138.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 601.7, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.97 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.97 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 595.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 793.06, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 595.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 613.98, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 607.84, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 595.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 674.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 583.28, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 4", "code_information": [ { "code": "6904", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 45078.63, "maximum": 48234.13, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10905, "minimum": 9573.6451, "maximum": 19760.911, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19480.08 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12694.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11123.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 10905.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10905.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12694.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10905.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11014.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12432.36, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10905.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14177.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10905.58, "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": 10905.58, "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": 19760.91, "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": 15333.25, "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": 15922.15, "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": 10905.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12824.96, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10905.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10905.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10905.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10905.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10905.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10905.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12694.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 16903.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17448.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12694.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13086.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12955.83, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10905.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12694.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10905.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18736.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10905.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19480.08 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12432.36, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "559", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17924, "minimum": 13410.7249, "maximum": 32479.194, "payers_information": [ { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21509.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21294.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20864.12, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24752.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31756.27 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20433.93, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31756.27 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20864.12, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18282.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20864.12, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18103.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20433.93, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23301.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17924.5, "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": 17924.5, "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": 32479.19, "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": 25201.85, "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": 26169.77, "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": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21079.21, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17924.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20864.12, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 27782.98, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28679.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20864.12, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "AFB CULTURE & SMEAR*LC", "code_information": [ { "code": "87116", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.41, "discounted_cash": 10, "minimum": 4.002, "maximum": 30.41, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.58 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.31, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 15.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.7, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.96, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.83, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.57, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.31, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC", "code_information": [ { "code": "284", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6783, "minimum": 6783.33, "maximum": 12676.51, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12676.51 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7895.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6919, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7895.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6851.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7733, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8818.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6783.33, "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": 6783.33, "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": 12291.39, "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": 9537.36, "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": 9903.66, "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": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7977.2, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7895.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10514.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10853.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7895.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8140, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8058.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7895.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9880.5 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6783.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12676.51 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7733, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AICD LEAD PROCEDURES", "code_information": [ { "code": "265", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34581, "minimum": 34581.6, "maximum": 72983.1156, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61025.15 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40253.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35273.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 34581.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 34581.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40253.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 34581.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 34927.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39423.05, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 34581.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 44956.11, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 34581.62, "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": 34581.62, "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": 62661.9, "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": 48621.76, "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": 50489.17, "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": 34581.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40667.99, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34581.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 34581.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 34581.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34581.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34581.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34581.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40253.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 53601.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 55330.59, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40253.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41497.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41082.96, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34581.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40253.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34581.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47565.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34581.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61025.15 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39423.05, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AFP TUMOR MARKER SERUM LC", "code_information": [ { "code": "82105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.77, "discounted_cash": 16, "minimum": 2.187, "maximum": 20.71, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19025, "minimum": 8243.4098, "maximum": 34474.3872, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33451.61 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22145.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19406.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22145.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19215.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21689.18, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24733.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19025.6, "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": 19025.6, "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": 34474.39, "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": 26749.99, "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": 27777.38, "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": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22374.11, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22145.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 29489.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30440.96, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22145.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22830.72, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22602.41, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22145.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33968.5 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19025.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33451.61 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21689.18, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "561", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7844, "minimum": 7844.53, "maximum": 16967.9432, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13986.93 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9131.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8001.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9131.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7922.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8942.76, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10197.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7844.53, "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": 7844.53, "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": 14214.29, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 11029.41, "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": 11453.01, "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": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9225.17, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9131.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 12159.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12551.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9131.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9413.44, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9319.3, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9131.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12002 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7844.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13986.93 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8942.76, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CCMCC", "code_information": [ { "code": "285", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5896, "minimum": 5896.94, "maximum": 26352.2352, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9604.04 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6864.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6014.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6864.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 5955.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6722.51, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7666.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 5896.94, "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": 5896.94, "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": 10685.26, "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": 8291.1, "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": 8609.53, "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": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6934.8, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6864.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 9140.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9435.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6864.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7076.33, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7005.56, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6864.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7486.36 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5896.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9604.04 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6722.51, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AICD GENERATOR PROCEDURES", "code_information": [ { "code": "245", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43551, "minimum": 25991.3925, "maximum": 83599.9341, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43551.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50694.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 67505.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 69683.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50694.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52262.33, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51739.7, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 43551.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50694.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43551.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 65160.9 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43551.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83599.93 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49649.21, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83599.93 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50694.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 44422.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 43551.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 43551.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50694.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 43551.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 43987.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49649.21, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 43551.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 56617.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 43551.94, "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": 43551.94, "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": 78916.12, "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": 61234.03, "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": 63585.83, "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": 43551.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51217.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 43551.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 43551.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 43551.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43551.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43551.94, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ACYLCARNITINE PROFILE, PLASMA", "code_information": [ { "code": "82017", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 167.73, "discounted_cash": 16, "minimum": 16.87, "maximum": 167.73, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.21, "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": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.81 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "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": 17.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.84, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.04, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALBUMIN SERUM", "code_information": [ { "code": "82040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37, "discounted_cash": 4, "minimum": 1, "maximum": 37, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.64, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.96 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.88, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.64, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY", "code_information": [ { "code": "895", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13655, "minimum": 8841.39, "maximum": 24769.6539, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24769.65 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15895.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13929.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 13655.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15895.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13655.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13792.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15567.78, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17752.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13655.95, "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": 13655.95, "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": 24744.58, "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": 19200.27, "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": 19937.69, "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": 13656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16059.4, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13655.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13655.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15895.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 21166.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21849.52, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15895.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16387.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16223.27, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15895.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13655.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8841.39 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13656, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24769.65 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15567.78, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADAMTS13 ANTIBODY", "code_information": [ { "code": "83520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 152, "discounted_cash": 17, "minimum": 3.942, "maximum": 690, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.31, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.72, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.69, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.69, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.28 } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALDOSTERONE SER/LC", "code_information": [ { "code": "82088", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.4, "discounted_cash": 40, "minimum": 5.52, "maximum": 50.31, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "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": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "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": 18.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AIRWAY INHALATION TREATMENT", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1194.14, "discounted_cash": 280, "minimum": 16.78, "maximum": 1322.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 420.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 283.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 319.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 609.02, "10th_percentile": 609.02, "90th_percentile": 609.02, "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": 394.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 409.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 329.59, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 434.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 336.31, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 332.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 319.5, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADDITIONAL RUN SERIAL CHANGER", "code_information": [ { "code": "75774", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 619, "minimum": 87.74, "maximum": 2413, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 363.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADDITIONAL VIEW EACH", "code_information": [ { "code": "78999", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 383, "discounted_cash": 511, "minimum": 43.5, "maximum": 383, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 383, "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": 383, "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": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383, "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": 383, "additional_payer_notes": "102.00% of Medicare Rates" } ] } ] }, { "description": "ALK PHOSPHATASE", "code_information": [ { "code": "84075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37, "discounted_cash": 5, "minimum": 4.662, "maximum": 37, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.85 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "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": 4.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.91, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.09, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.22, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.15, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.91, "additional_payer_notes": "114.00% 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADDL VES PTA TIBIAL/PERONEAL", "code_information": [ { "code": "37232", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21184.9, "minimum": 180.3585, "maximum": 21184.9, "payers_information": [ { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 180.36 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC", "code_information": [ { "code": "896", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16786, "minimum": 10176, "maximum": 30464.6727, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30464.67 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19539.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17122.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 16786.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16786.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19539.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16786.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16954.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19136.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16786.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 21822.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16786.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16786.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30416.87, "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": 23601.61, "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": 24508.07, "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": 16786.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19740.75, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16786.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16786.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16786.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16786.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16786.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16786.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19539.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 26018.84, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26858.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19539.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20143.62, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19942.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16786.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19539.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16786.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14082.6 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16786.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30464.67 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19136.44, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN PROFILE, FOOD LC", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39.12, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 3", "code_information": [ { "code": "7753", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8305.88, "maximum": 8887.29, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADJ TISSUE TRSF,10.1-30SQ CM - 14041 - 02696", "code_information": [ { "code": "14041", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6597, "discounted_cash": 2640, "minimum": 605.06, "maximum": 6597, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 3374.39, "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": 605.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 635.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3712.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3855.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 647.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3105.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4093.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3168.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3137.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC", "code_information": [ { "code": "897", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8594, "minimum": 6996, "maximum": 15572.5454, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15092.06 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10003.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8766, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10003.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9797.3, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11172.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8594.12, "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": 8594.12, "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": 15572.55, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 12083.33, "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": 12547.42, "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": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10106.69, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10003.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13320.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13750.59, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10003.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10312.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10209.81, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10003.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8594.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15092.06 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9797.3, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN W/TOTAL IGE AREA13 LC", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42.87, "discounted_cash": 16, "minimum": 11.394, "maximum": 106.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.24 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.76, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.36, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.55, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.76, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 4", "code_information": [ { "code": "7754", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19303.36, "maximum": 20654.6, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "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" } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Allergens (7) Seafood", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.82, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA", "code_information": [ { "code": "894", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6067, "minimum": 4452, "maximum": 10995.1254, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10676.66 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7063.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6189.31, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7063.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6128.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6917.46, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7888.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6067.95, "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": 6067.95, "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": 10995.13, "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": 8531.54, "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": 8859.21, "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": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7135.91, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7063.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 9405.32, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9708.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7063.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7281.54, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7208.72, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7063.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4634.53 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6067.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10676.66 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6917.46, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITH CCMCC", "code_information": [ { "code": "614", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21030, "minimum": 16664.2637, "maximum": 38987.53, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38987.53 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24479.14, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21450.8, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 21030.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21030.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24479.14, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 21030.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21240.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23974.42, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21030.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 27339.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21030.19, "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": 21030.19, "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": 38106.7, "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": 29568.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30704.08, "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": 21030.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24731.5, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21030.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21030.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 21030.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21030.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21030.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21030.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24479.14, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 32596.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33648.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24479.14, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25236.23, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24983.87, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21030.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24479.14, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21030.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32659.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21030.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38987.53 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23974.42, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGENS (7) SEAFOODS LC", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.52, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL ANGIOGRAM 2 SIDE", "code_information": [ { "code": "75733", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2671, "discounted_cash": 4041, "minimum": 148.76, "maximum": 2671, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 394.67 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2671, "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": 148.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2671, "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": 2671, "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": 159.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2671, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALKALINE PHOS ISOENZYME LC", "code_information": [ { "code": "84080", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.34, "discounted_cash": 14, "minimum": 13.302, "maximum": 44.34, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.89, "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": 15.08 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 20.8 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "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": 15.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.17, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.85, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.38, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.74, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.56, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.85, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 1", "code_information": [ { "code": "8111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2829.41, "maximum": 3027.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALDOSTERONE, LC/MS", "code_information": [ { "code": "82088", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.4, "discounted_cash": 40, "minimum": 5.52, "maximum": 50.31, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "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": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "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": 18.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGEN PEDIATRIC 0-3 YRS", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 121.25, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16183, "minimum": 7934.9667, "maximum": 29730.77, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29730.77 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18837.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16506.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 16183.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16183.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18837.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16183.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16344.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18448.7, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16183.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 21037.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16183.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16183.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29323.72, "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": 22753.4, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23627.28, "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": 16183.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19031.29, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16183.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16183.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16183.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16183.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16183.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16183.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18837.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 25083.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25892.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18837.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19419.68, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19225.49, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16183.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18837.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16183.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18497.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16183.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29730.77 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18448.7, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 4", "code_information": [ { "code": "4014", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 45294.89, "maximum": 48465.53, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGEN PROFILE FOOD MEAT LC", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.78, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 3", "code_information": [ { "code": "0073", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 89273.14, "maximum": 95522.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGEN PROFILE,LATEX RELATED", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 121.25, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AEROBIC BACTERIAL CULT LC", "code_information": [ { "code": "87070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.86, "discounted_cash": 8, "minimum": 2.697, "maximum": 134, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.83, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 61.72, "10th_percentile": 61.72, "90th_percentile": 61.72, "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": 12.12 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.24, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.83, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN SPEC IGE RECOMB EA", "code_information": [ { "code": "86008", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.65, "discounted_cash": 17, "minimum": 2.595, "maximum": 8.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AEROBIC SENSITIVITY", "code_information": [ { "code": "87186", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 96, "discounted_cash": 8, "minimum": 1.5, "maximum": 115, "payers_information": [ { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.98, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.86, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.17, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.28, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.86, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ALLOG SKIN SUBS FACE/FT*1ST100", "code_information": [ { "code": "15277", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 670.4, "discounted_cash": 2640, "minimum": 177.21, "maximum": 8687.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "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": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 186.01 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "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": 177.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "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": 670.4, "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": 189.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN SPECIFIC IGE QN/SC", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.65, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AEROSOL INITIAL SETUP 1 TM CHG", "code_information": [ { "code": "94664", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 500, "discounted_cash": 280, "minimum": 12.34, "maximum": 500, "payers_information": [ { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 434.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 336.31, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 332.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 319.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "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": 12.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 420.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 283.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 319.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 394.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 409.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 329.59, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 326.22, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN W/TOTAL IGE AREA12 LC", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.98, "discounted_cash": 16, "minimum": 11.394, "maximum": 106.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.24 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.76, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.36, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.55, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.76, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AFB ID DNA PROBE LC", "code_information": [ { "code": "87149", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 109.75, "discounted_cash": 20, "minimum": 12.99, "maximum": 208.8, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.45, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.05 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.86, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 28.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.19 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 31.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.06, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.86, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 2", "code_information": [ { "code": "8112", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4082.45, "maximum": 4368.22, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFP WITH AFP-L3% LC", "code_information": [ { "code": "82107", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 75, "discounted_cash": 64, "minimum": 22.5, "maximum": 75, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 65.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 74.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 60.12 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 65.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 73.43, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.02 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 74.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 74.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 74.97, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 73.43, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOG SKIN SUBS FACE/FT ADD100", "code_information": [ { "code": "15278", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 670.4, "minimum": 45.42, "maximum": 3811, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 47.52 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 } ] } ] }, { "description": "AFTERCARE WITHOUT CCMCC", "code_information": [ { "code": "950", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6170, "minimum": 6170.56, "maximum": 23658, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10026.59 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7182.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6293.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7182.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6232.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7034.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8021.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11181.05, "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": 8675.81, "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": 9009.02, "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": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7256.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7182.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 9564.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9872.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7182.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7404.67, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7330.63, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7182.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23658 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6170.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10026.59 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7034.44, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 2", "code_information": [ { "code": "0072", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 66446.01, "maximum": 71097.23, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALA DELTA,RANDOM URINE", "code_information": [ { "code": "82135", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.04, "discounted_cash": 16, "minimum": 8.112, "maximum": 27.04, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.78, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.15, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.23 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.75, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.13 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.02 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.15, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.15, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.54, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.15, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.75, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMBULANCE SERVICE-BASIC", "code_information": [ { "code": "A0428", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 752, "discounted_cash": 327, "minimum": 107.16, "maximum": 1052, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 431.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 418.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 333.98, "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": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 381.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 112.52 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "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": 107.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 491.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 330.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 373.27, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 458.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 460.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 478.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 385.06, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 381.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 507.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 381.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 392.92, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 388.99, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 381.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 431.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 373.27, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "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" } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMBULANCE SERVICE-ADVANCE", "code_information": [ { "code": "A0428", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1052, "discounted_cash": 327, "minimum": 107.16, "maximum": 1052, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 431.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 418.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 333.98, "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": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 381.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 112.52 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "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": 107.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 491.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 330.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 373.27, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 458.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 460.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 478.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 385.06, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 381.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 507.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 381.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 392.92, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 388.99, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 381.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 107.16 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 327.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 431.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 373.27, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMIDATE 20 MG/10 ML", "drug_information": { "unit": 10, "type": "ML" }, "code_information": [ { "code": "55390076210", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 40.4, "median_amount": 19.4, "10th_percentile": 19.4, "90th_percentile": 19.4, "count": "1 through 10" } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMEBIASIS ANTIBODIES LLC", "code_information": [ { "code": "86753", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.45, "discounted_cash": 12, "minimum": 8.1, "maximum": 37.45, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 17.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.09 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 19.2, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.87, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMIKACIN PEAK/QUEST", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 61, "discounted_cash": 15, "minimum": 1, "maximum": 439.8, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.19, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 21.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.02 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.73, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.1, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.19, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL BLOOD", "code_information": [ { "code": "80307", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "discounted_cash": 62, "minimum": 2.7, "maximum": 359.15, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 45.68 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 105.04, "10th_percentile": 105.04, "90th_percentile": 105.04, "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": 66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.55 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 } ] } ] }, { "description": "AMIKACIN TROUGH LC", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.5, "discounted_cash": 15, "minimum": 1, "maximum": 439.8, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMIKACIN* EHMC", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 439.8, "discounted_cash": 15, "minimum": 1, "maximum": 439.8, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.19, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 21.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.02 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.73, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.1, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.19, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 1", "code_information": [ { "code": "2801", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4881.76, "maximum": 5223.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMINO ACID PROFILE, QN PLASMA", "code_information": [ { "code": "82139", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130.52, "discounted_cash": 16, "minimum": 6.249, "maximum": 130.52, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.21, "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": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.81 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "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": 17.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.84, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.04, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMMONIA BLOOD", "code_information": [ { "code": "82140", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 150, "discounted_cash": 14, "minimum": 14.57, "maximum": 150, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.86, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.61, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.13, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.61, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALOG SKIN TRNK/ARM/LEG*ADD 100", "code_information": [ { "code": "15274", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 670.4, "minimum": 36.49, "maximum": 3720.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 38.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 } ] } ] }, { "description": "ALDOLASE/LC", "code_information": [ { "code": "82085", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.85, "discounted_cash": 9, "minimum": 1, "maximum": 11.99, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "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": 2.85 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2.85 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "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": 2.85 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.85 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.85, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMINOPHYLLINE/THEOPH", "code_information": [ { "code": "80198", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71, "discounted_cash": 14, "minimum": 14.14, "maximum": 71, "payers_information": [ { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.07, "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": 14.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 19.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.64 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.63, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.92, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.97, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ALDOSTERONE", "code_information": [ { "code": "82088", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.31, "discounted_cash": 40, "minimum": 5.52, "maximum": 50.31, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.31, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.31, "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": 41.56 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.43, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 50.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.46, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 50.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 50.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.92, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.43, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 50.31, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.43, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.9, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.41, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.43, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.31, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.46, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Amiodarone ( Cordarone )*LC", "code_information": [ { "code": "82542", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.16, "discounted_cash": 24, "minimum": 2.91, "maximum": 131.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 20.16 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CCMCC", "code_information": [ { "code": "241", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13359, "minimum": 13359.5, "maximum": 38023.0552, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25830.31 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15550.5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13626.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 13359.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13359.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15550.5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13359.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13493.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15229.88, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13359.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17367.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13359.54, "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": 13359.54, "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": 24207.49, "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": 18783.51, "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": 19504.93, "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": 13359.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15710.82, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13359.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13359.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13359.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13359.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13359.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13359.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15550.5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 20707.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21375.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15550.5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16031.45, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15871.13, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13359.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15550.5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13359.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20133.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13359.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25830.31 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15229.88, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALPH-1-ANTITRYPSIN/LC", "code_information": [ { "code": "82103", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.26, "discounted_cash": 13, "minimum": 1.578, "maximum": 61.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "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": 5.26 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "475", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21827, "minimum": 21827.28, "maximum": 39551.0314, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36905.57 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25406.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22263.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 21827.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21827.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25406.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 21827.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22045.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24883.1, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21827.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 28375.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21827.28, "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": 21827.28, "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": 39551.03, "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": 30689.16, "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": 31867.83, "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": 21827.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25668.88, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21827.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21827.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 21827.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21827.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21827.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21827.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25406.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 33832.28, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34923.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25406.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26192.74, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25930.81, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21827.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25406.95, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21827.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25117.5 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21827.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36905.57 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24883.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "474", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40991, "minimum": 40991.57, "maximum": 76721.0904, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76721.09 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47714.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 41811.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 40991.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 40991.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47714.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 40991.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 41401.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46730.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 40991.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 53289.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 40991.57, "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": 40991.57, "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": 74276.72, "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": 57634.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 59847.69, "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": 40991.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48206.09, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40991.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 40991.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 40991.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40991.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40991.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40991.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47714.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 63536.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 65586.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47714.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49189.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48697.99, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40991.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47714.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40991.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 69294.5 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40991.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76721.09 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46730.39, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "476", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11419, "minimum": 10335.8, "maximum": 20692.2246, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19897.5 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13292.36, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11647.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 11419.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11419.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13292.36, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11419.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11533.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13018.29, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11419.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14845.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11419.55, "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": 11419.55, "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": 20692.22, "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": 16055.89, "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": 16672.54, "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": 11419.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13429.39, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11419.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11419.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11419.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11419.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11419.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11419.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13292.36, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17700.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18271.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13292.36, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13703.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13566.43, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11419.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13292.36, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11419.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10335.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11419.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19897.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13018.29, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 2", "code_information": [ { "code": "3052", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12581.27, "maximum": 13461.96, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMYLASE OTHER BODY FL", "code_information": [ { "code": "82150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39, "discounted_cash": 6, "minimum": 6.48, "maximum": 43, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.62, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.7, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "102.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN SPECIFIC IGE QN/SQ LC - 86003 - 45137", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42.88, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANA Comprehensive Panel*LC", "code_information": [ { "code": "86225", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 116.75, "discounted_cash": 13, "minimum": 2.187, "maximum": 116.75, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.01, "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": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.99, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "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": 14.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.61, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.66, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 19.24, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.06 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.01 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.16, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.01 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.99, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.99, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.32, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.99, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.66, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAEROBIC CULTURE", "code_information": [ { "code": "87075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "discounted_cash": 9, "minimum": 3.057, "maximum": 180, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.07 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGEN SPECIFIC IGE QN/SQ LC - 86003 - 45140", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40.62, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH CC", "code_information": [ { "code": "348", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12641, "minimum": 12641.3, "maximum": 29676.0371, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21536.37 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14714.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12894.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 12641.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12641.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14714.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12641.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12767.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14411.09, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12641.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 16433.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12641.31, "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": 12641.31, "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": 22906.05, "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": 17773.68, "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": 18456.31, "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": 12641.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14866.18, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12641.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12641.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12641.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12641.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12641.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12641.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14714.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 19594.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20226.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14714.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15169.57, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15017.88, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12641.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14714.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12641.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16142.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12641.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21536.37 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14411.09, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAEROBIC CULTURE LC - 87075 - 45314", "code_information": [ { "code": "87075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.4, "discounted_cash": 9, "minimum": 3.057, "maximum": 180, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMIKACIN PEAK SERUM LC", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5, "discounted_cash": 15, "minimum": 1, "maximum": 439.8, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 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": 5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN SPECIFIC IGE QN/SQ LC - 86003 - 45142", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.99, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANALYSIS W/ INFUSION PUMP", "code_information": [ { "code": "62368", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 382, "discounted_cash": 393, "minimum": 51.5865, "maximum": 382, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "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": 382, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 51.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 382, "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": 382, "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": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAEROBIC CULTURE LC - 87075 - 45332", "code_information": [ { "code": "87075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.66, "discounted_cash": 9, "minimum": 3.057, "maximum": 180, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.07 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.66, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMIKACIN TROUGH", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 116, "discounted_cash": 15, "minimum": 1, "maximum": 439.8, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.19, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 21.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.02 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.73, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.1, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.19, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN W/TOTAL IGE AREA17 LC", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40.62, "discounted_cash": 16, "minimum": 11.394, "maximum": 106.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.24 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.76, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.36, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.51, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.55, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.76, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANCA*LC", "code_information": [ { "code": "83516", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.58, "discounted_cash": 11, "minimum": 1.245, "maximum": 220, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.56, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.7, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 2", "code_information": [ { "code": "2262", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8216.84, "maximum": 8792.02, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMIKACIN*ENC", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.39, "discounted_cash": 15, "minimum": 1, "maximum": 439.8, "payers_information": [ { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "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": 10.39 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "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": 10.39 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10.39, "additional_payer_notes": "140.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGENS W/TOTAL IGE LC", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 83.13, "discounted_cash": 5, "minimum": 2.595, "maximum": 121.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 3", "code_information": [ { "code": "2263", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12875.97, "maximum": 13777.29, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANKLE COMPLETE", "code_information": [ { "code": "73610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 239, "discounted_cash": 111, "minimum": 26.32, "maximum": 311.5, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 37.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "349", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8478, "minimum": 8478.21, "maximum": 18155.2705, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9970.37, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9868.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 13141.23, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13565.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9868.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10173.85, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10072.11, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9868.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8865.42 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15069.82 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9665.16, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15069.82 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9868.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8647.77, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9868.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8562.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9665.16, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8478.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11021.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8478.21, "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": 8478.21, "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": 15362.52, "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": 11920.36, "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": 12378.19, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 4", "code_information": [ { "code": "3054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 31219.94, "maximum": 33405.34, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITHOUT MCC", "code_information": [ { "code": "916", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6537, "minimum": 5306.05, "maximum": 18678.0756, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11360.96 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7609.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6668.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7609.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6602.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7452.49, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8498.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6537.27, "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": 6537.27, "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": 11845.53, "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": 9191.4, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9544.41, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7687.83, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7609.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10132.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10459.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7609.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7844.72, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7766.28, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7609.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5306.05 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6537.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11360.96 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7452.49, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE LEFT BRACHIAL PRESSURES", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 337, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANALYSIS ANTITACHY PM SYSTEM", "code_information": [ { "code": "93724", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 135, "discounted_cash": 393, "minimum": 40.5, "maximum": 135, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "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 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 135 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 135, "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 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 135, "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": 135, "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": 135 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 135 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 135 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 135 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 135 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC", "code_information": [ { "code": "616", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33338, "minimum": 22273.4027, "maximum": 66119.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66119.7 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38806.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 34005.78, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 33338.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 33339, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38806.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 33338.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33672.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38006.41, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 33339, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 43340.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 33338.96, "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": 33338.96, "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": 60410.2, "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": 46874.58, "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": 48674.88, "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": 33339, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39206.62, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33339, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33338.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 33339, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33339, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33338.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33339, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38806.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 51675.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53342.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38806.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40006.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39606.68, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33339, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38806.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33338.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29495 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33339, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66119.7 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38006.41, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE RIGHT AP AND LATERAL", "code_information": [ { "code": "73600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 311.5, "discounted_cash": 111, "minimum": 19.92, "maximum": 311.5, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.64 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANCA PANEL*LC", "code_information": [ { "code": "83516", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.58, "discounted_cash": 11, "minimum": 1.245, "maximum": 220, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.56, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.7, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMYLASE SERUM", "code_information": [ { "code": "82150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 43, "discounted_cash": 6, "minimum": 6.48, "maximum": 43, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.04, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.7, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.62, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 } ] } ] }, { "description": "ANKLE RIGHT W/WO CONT - 73723 - 70964", "code_information": [ { "code": "73723", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3450, "discounted_cash": 446, "minimum": 300.2, "maximum": 3450, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "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": 300.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 404.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 300.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 300.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 300.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 300.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 300.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANCA SCREEN EA AB", "code_information": [ { "code": "86036", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 82.5, "discounted_cash": 12, "minimum": 12.05, "maximum": 82.5, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.65 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.17, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 1", "code_information": [ { "code": "2261", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6668.03, "maximum": 7134.79, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOG SKIN TRNK/ARM/LEG*1ST100", "code_information": [ { "code": "15273", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 670.4, "discounted_cash": 2640, "minimum": 172, "maximum": 17091.3, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "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": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 180.57 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "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": 172 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "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": 670.4, "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": 184.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE RIGHT WCONT", "code_information": [ { "code": "73701", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1301, "discounted_cash": 224, "minimum": 175.82, "maximum": 1301, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 228.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 377.64 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "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": 175.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 336.72, "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": 226.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 255.91, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 314.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "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": 224.48, "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": 315.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.74, "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": 188.13 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 175.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 263.99, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 347.94, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 269.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 266.68, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 295.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 255.91, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 295.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 286.85, "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": 175.82 } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT", "code_information": [ { "code": "014", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 114382, "minimum": 114382, "maximum": 224136.3707, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 224136.37 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 133141.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 116669.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 114382.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 114382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 133141.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 114382.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 115525.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 130396.02, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 114382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 148697.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 114382.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 114382.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 207261.04, "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": 160821.75, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 166998.41, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 114382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 134513.78, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 114382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 114382.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 114382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 114382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 114382.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 114382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 133141.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 177292.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 183011.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 133141.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 137258.96, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 135886.37, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 114382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 133141.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 114382.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 141094 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 114382, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 224136.37 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 130396.02, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 2", "code_information": [ { "code": "0592", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7339.07, "maximum": 7852.8, "payers_information": [ { "payer_name": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANEROBIC ID", "code_information": [ { "code": "87076", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160, "discounted_cash": 8, "minimum": 8.08, "maximum": 160, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.03 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.21, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.5, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.52, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.21, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANES ADDL 15 MIN", "code_information": [ { "code": "Z7508", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12480, "minimum": 58.47, "maximum": 12480, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 } ] }, { "setting": "outpatient", "gross_charge": 12480, "minimum": 58.47, "maximum": 12480, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.39 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11490.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "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" } ] } ] }, { "description": "ANES 1ST 60 MIN", "code_information": [ { "code": "Z7506", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12456, "minimum": 146.17, "maximum": 12456, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 153.48 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 156.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 } ] }, { "setting": "outpatient", "gross_charge": 12456, "minimum": 146.17, "maximum": 12456, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 153.48 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 156.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 1", "code_information": [ { "code": "1981", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3984.92, "maximum": 4263.86, "payers_information": [ { "payer_name": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 2", "code_information": [ { "code": "5472", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8566.24, "maximum": 9165.88, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 4", "code_information": [ { "code": "1984", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10894.65, "maximum": 11657.28, "payers_information": [ { "payer_name": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGIOGRAPHY EXT LT UNILATERAL", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 234.6, "discounted_cash": 4041, "minimum": 70.38, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.6 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "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": 130.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 4", "code_information": [ { "code": "0524", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15262.26, "maximum": 16330.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGIO AORTA ABD W/ LE*RUNOFF", "code_information": [ { "code": "75630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9197, "discounted_cash": 4041, "minimum": 104.04, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "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": 104.04 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 426.22 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 104.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4606.9, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 111.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4752.38, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4849.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4800.87, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4606.9, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOJET THROMBECTOMY", "code_information": [ { "code": "37799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7591, "discounted_cash": 802, "minimum": 802.86, "maximum": 7591, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1057.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1025.92, "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": 818.92, "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": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1204.29, "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": 810.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 915.26, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1124, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "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": 802.86, "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": 1128.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1172.18, "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": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 944.16, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1244.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 963.43, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 953.8, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 802.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1057.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 915.26, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMINO ACIDS QUAN 6+", "code_information": [ { "code": "82139", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.83, "discounted_cash": 16, "minimum": 6.249, "maximum": 130.52, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.21, "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": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 20.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "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": 17.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.83, "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": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.84, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.04, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 3", "code_information": [ { "code": "5663", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6022.96, "maximum": 6444.57, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGIOPL TRNLM ILIAC PERC", "code_information": [ { "code": "37220", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 7142, "minimum": 371.049, "maximum": 12576.6, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9409.13, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9126.86, "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": 7285.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8313.84, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 371.05 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10713.71, "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": 7213.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8142.42, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9999.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "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": 7142.47, "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": 10042.31, "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": 10428.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8399.54, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8313.84, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11070.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8313.84, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8570.96, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8485.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8313.84, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7142.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9409.13, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8142.42, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOPL TRNLM AORTIC PERC - 37246 - 95434", "code_information": [ { "code": "37246", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20964.9, "discounted_cash": 7284, "minimum": 58.2, "maximum": 25425, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11290.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8741.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8653.9, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9308.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7430.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2058.56 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "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": 1960.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10926.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7357.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10198.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10241.91, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10635.27, "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": 2097.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8566.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "AMINOCENTESIS ULTRASOUND", "code_information": [ { "code": "76946", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 757, "minimum": 17.26, "maximum": 757, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.26 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 17.26 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.26 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.26 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.26 } ] } ] }, { "description": "ANTHRAX CULTURE/FOCUS", "code_information": [ { "code": "87070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 129, "discounted_cash": 8, "minimum": 2.697, "maximum": 134, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.83, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.12 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.36, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.24, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.83, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOPL TRNLM RENAL VISC PERC - 37246 - 95589", "code_information": [ { "code": "37246", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 7284, "minimum": 58.2, "maximum": 25425, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9308.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7430.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2058.56 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "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": 1960.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10926.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7357.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10198.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10241.91, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10635.27, "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": 2097.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8566.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11290.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8741.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8653.9, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOPL TRNLM AORTIC PERC - 37246 - 95590", "code_information": [ { "code": "37246", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 7284, "minimum": 58.2, "maximum": 25425, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9308.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7430.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2058.56 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "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": 1960.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10926.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7357.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10198.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10241.91, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10635.27, "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": 2097.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8566.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11290.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8741.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8653.9, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC", "code_information": [ { "code": "240", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 27288, "minimum": 16486.8196, "maximum": 49819.87, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 27288.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 27288.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31763.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 27288.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 27560.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31108.47, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 27288.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 35474.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 27288.13, "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": 27288.13, "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": 49446.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 38367.11, "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": 39840.67, "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": 27288.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32090.84, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27288.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 27288.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 27288.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27288.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 27288.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27288.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31763.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 42296.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 43661.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31763.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32745.76, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32418.3, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 27288.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31763.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 27288.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25034.6 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27288.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49819.87 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31108.47, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49819.87 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31763.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 27833.86, "additional_payer_notes": "102.00% of Medicare Rates" } ] } ] }, { "description": "ANTI-CENTROMERE AB LC", "code_information": [ { "code": "86256", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 83, "discounted_cash": 12, "minimum": 2.355, "maximum": 83, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.17, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOPL TRNLM RENAL VISC PERC - 37246 - 95601", "code_information": [ { "code": "37246", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 7284, "minimum": 58.2, "maximum": 25425, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9308.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7430.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2058.56 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "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": 1960.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10926.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7357.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10198.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10241.91, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10635.27, "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": 2097.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8566.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11290.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8741.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8653.9, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOPL TRNLM BRACHIOCEPH PERC", "code_information": [ { "code": "37247", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "minimum": 307.5, "maximum": 22696.1, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.65 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 900.87 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 844.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 789.65 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.65 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.65 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.65 } ] } ] }, { "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": 46965, "minimum": 33946.6045, "maximum": 86167.74, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86167.74 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54667.78, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 47904.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 46965.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 46965.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54667.78, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 46965.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 47435.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53540.61, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 46965.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 61055.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 46965.45, "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": 46965.45, "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": 85101.4, "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": 66033.42, "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": 68569.56, "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": 46965.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55231.37, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46965.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 46965.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 46965.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46965.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46965.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46965.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54667.78, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 72796.45, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 75144.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54667.78, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56358.54, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55794.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 46965.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54667.78, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46965.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47539.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46965.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86167.74 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53540.61, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTI-MITOCHON AB.PAML", "code_information": [ { "code": "86255", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.76, "discounted_cash": 12, "minimum": 2.628, "maximum": 129, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOPL TRNLM TIBIOPERON PERC", "code_information": [ { "code": "37229", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 22494, "minimum": 643.9125, "maximum": 44975.1, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 643.91 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOPL TRNLM RENAL VISC PERC - 37246 - 95433", "code_information": [ { "code": "37246", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20964.9, "discounted_cash": 7284, "minimum": 58.2, "maximum": 25425, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9308.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7430.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2058.56 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "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": 1960.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10926.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7357.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10198.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10241.91, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10635.27, "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": 2097.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8566.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11290.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8741.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8653.9, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1960.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC", "code_information": [ { "code": "617", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17975, "minimum": 16890.5347, "maximum": 33044.453, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26244.67, "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": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21139.54, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20923.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 27862.49, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28761.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20923.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21570.96, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21355.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20923.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18260.6 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33044.45 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20492.41, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33044.45 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20923.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18335.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20923.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18155.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20492.41, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17975.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23368.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17975.8, "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": 17975.8, "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": 32572.15, "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": 25273.97, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "ANTI-MULLERIAN HORMONE", "code_information": [ { "code": "82397", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.43, "discounted_cash": 14, "minimum": 4.398, "maximum": 400, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.43 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 17.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.61, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOPL TRNLM VENOUS PERC", "code_information": [ { "code": "37248", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 7284, "minimum": 463.5, "maximum": 25425, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9308.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1351.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7430.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1419.41 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "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": 1351.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10926.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7357.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10198.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10241.91, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10635.27, "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": 1446.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1351.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8566.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1351.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1351.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11290.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8741.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8653.9, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8479.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1351.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7284.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9596.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8304.25, "additional_payer_notes": "114.00% 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": 13681, "minimum": 13681.6, "maximum": 34386.0466, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21300.29 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15925.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13955.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15925.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13818.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15597.02, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17786.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13681.6, "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": 13681.6, "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": 24791.06, "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": 19236.33, "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": 19975.14, "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": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16089.56, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15925.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 21206.48, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21890.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15925.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16417.92, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16253.74, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15925.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16602.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13681.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21300.29 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15597.02, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTI-MYOCARDIAL AB", "code_information": [ { "code": "86256", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.71, "discounted_cash": 12, "minimum": 2.355, "maximum": 83, "payers_information": [ { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 15.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.71 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.71 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.17, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.71, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.71 } ] } ] }, { "description": "ANKLE LEFT W/CONT - 73701 - 71061", "code_information": [ { "code": "73701", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1301, "discounted_cash": 224, "minimum": 175.82, "maximum": 1301, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 295.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 286.85, "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": 175.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 228.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 377.64 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "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": 175.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 336.72, "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": 226.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 255.91, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 314.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "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": 224.48, "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": 315.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.74, "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": 188.13 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 175.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 263.99, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 347.94, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 269.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 266.68, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 295.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 255.91, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Amputation of toe", "code_information": [ { "code": "28820", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12456, "discounted_cash": 4187, "minimum": 327.36, "maximum": 12456, "payers_information": [ { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4874.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5025.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4975, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4874.49, "additional_payer_notes": "116.40% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4773.99, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 5351.18, "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": 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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4874.49, "additional_payer_notes": "116.40% 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": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4773.99, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4924.75, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4874.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 12456, "discounted_cash": 4187, "minimum": 327.36, "maximum": 12456, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 5351.18, "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": 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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4874.49, "additional_payer_notes": "116.40% 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": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4773.99, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4924.75, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4874.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6490.95, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4874.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5025.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4975, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4874.49, "additional_payer_notes": "116.40% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4773.99, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE LEFT W/WO CONT - 73702 - 71075", "code_information": [ { "code": "73702", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1738, "discounted_cash": 224, "minimum": 214.7, "maximum": 1738, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 295.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 286.85, "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": 214.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 228.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 459.12 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "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": 214.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 336.72, "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": 226.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 255.91, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 314.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "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": 224.48, "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": 315.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.74, "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": 229.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 214.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 263.99, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 214.7 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 214.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 347.94, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 269.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 266.68, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 214.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 295.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 255.91, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE LEFT AP AND LATERAL", "code_information": [ { "code": "73600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 311.5, "discounted_cash": 111, "minimum": 19.92, "maximum": 311.5, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.64 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTI-SM AB LC", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.25, "discounted_cash": 17, "minimum": 2.319, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 27.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.52, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE RIGHT BRACHIAL PRESSURES", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 468, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE LEFT COMPLETE", "code_information": [ { "code": "73610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 311.5, "discounted_cash": 111, "minimum": 26.32, "maximum": 311.5, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 37.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 4", "code_information": [ { "code": "2264", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21704.49, "maximum": 23223.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTI-TPO AB (RDL) LC", "code_information": [ { "code": "86376", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "discounted_cash": 14, "minimum": 2.064, "maximum": 66, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.11, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22.55, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE RIGHT COMPLETE", "code_information": [ { "code": "73610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 311.5, "discounted_cash": 111, "minimum": 26.32, "maximum": 311.5, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 37.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.16 } ] } ] }, { "description": "ANKLE LEFT W/CONT - 73722 - 70963", "code_information": [ { "code": "73722", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3450, "discounted_cash": 1003, "minimum": 250.41, "maximum": 3450, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1282.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1023.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1167.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 328.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "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": 250.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1504.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1013.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1143.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1404.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1410.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1464.83, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 267.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1179.89, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1167.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1555.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1167.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1203.97, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1191.93, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1167.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1143.77, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH MCC", "code_information": [ { "code": "347", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22016, "minimum": 10367.9754, "maximum": 40489.55, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40489.55 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25627.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22456.63, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 22016.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22016.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25627.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 22016.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22236.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25098.63, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22016.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 28621.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22016.34, "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": 22016.34, "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": 39893.61, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 30954.97, "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": 32143.86, "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": 22016.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25891.22, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22016.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22016.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 22016.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22016.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22016.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22016.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25627.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 34125.33, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35226.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25627.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26419.61, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26155.41, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22016.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25627.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22016.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31558.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22016.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40489.55 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25098.63, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTI-U1 RNP Ab", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34, "discounted_cash": 17, "minimum": 2.319, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 27.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.52, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE RIGHT W/O CONT - 73700 - 71044", "code_information": [ { "code": "73700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1463, "discounted_cash": 133, "minimum": 131.98, "maximum": 1463, "payers_information": [ { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 141.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 317.98 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE LEFT W/WO CONT - 73723 - 70965", "code_information": [ { "code": "73723", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3450, "discounted_cash": 446, "minimum": 300.2, "maximum": 3450, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "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": 300.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 404.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 300.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 300.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 300.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 300.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 692.08, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 300.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANALYSIS W/O INFUSION PUMP", "code_information": [ { "code": "62367", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 323, "discounted_cash": 393, "minimum": 33.0855, "maximum": 323, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "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": 323, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 33.09 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 323, "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": 323, "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": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 323, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTINUCLEAR ANTIBODIES by IFA", "code_information": [ { "code": "86038", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 105, "discounted_cash": 12, "minimum": 1.248, "maximum": 105, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.78, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.22, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.51, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.36, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.78, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE RIGHT W/WO CONT - 73702 - 71074", "code_information": [ { "code": "73702", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1738, "discounted_cash": 224, "minimum": 214.7, "maximum": 1738, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 295.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 286.85, "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": 214.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 228.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 459.12 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "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": 214.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 336.72, "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": 226.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 255.91, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 314.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "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": 224.48, "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": 315.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.74, "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": 229.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 214.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 263.99, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 214.7 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 214.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 347.94, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 269.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 266.68, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 261.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 214.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 224.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 295.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 255.91, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE RIGHT W/CONT", "code_information": [ { "code": "73722", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3450, "discounted_cash": 1003, "minimum": 250.41, "maximum": 3450, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1282.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1023.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1167.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 328.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "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": 250.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1504.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1013.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1143.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1404.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1410.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1464.83, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 267.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1179.89, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1167.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1555.13, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1167.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1203.97, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1191.93, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1167.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 250.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1143.77, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTISCLERODERMA-70 AB", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.46, "discounted_cash": 17, "minimum": 2.319, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE RIGHT W/O CONT - 73721 - 70960", "code_information": [ { "code": "73721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2800, "discounted_cash": 305, "minimum": 206.2, "maximum": 2800, "payers_information": [ { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 473.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 366.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 362.79, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 348.13, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 588.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 308.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 348.13, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 429.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 445.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 220.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 359.13, "additional_payer_notes": "117.60% of Medicare Rates" } ] } ] }, { "description": "ANTIVERT - 35356091490", "drug_information": { "unit": 25, "type": "ME" }, "code_information": [ { "code": "35356091490", "type": "NDC" }, { "code": "J8597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 8.96, "10th_percentile": 8.96, "90th_percentile": 9.16, "count": "1 through 10" } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC", "code_information": [ { "code": "269", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40329, "minimum": 8239.56, "maximum": 73076.8547, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71178.33 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46943.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 41135.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 40329.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 40329.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46943.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 40329.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 40732.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45975.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 40329.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 52428.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 40329.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 40329.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 73076.85, "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": 56703.12, "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": 58880.91, "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": 40329.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47427.36, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40329.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 40329.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 40329.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40329.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40329.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40329.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46943.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 62510.55, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 64527.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46943.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48395.27, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47911.32, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40329.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46943.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40329.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8239.56 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40329.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71178.33 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45975.5, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANOSCOPY HRA DX W/COLLECTION", "code_information": [ { "code": "46601", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 259.1, "discounted_cash": 571, "minimum": 77.73, "maximum": 259.1, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "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": 259.1, "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": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 110.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "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": 259.1, "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": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 259.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 3", "code_information": [ { "code": "5473", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13219.02, "maximum": 14144.35, "payers_information": [ { "payer_name": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Apolipoprotein B", "code_information": [ { "code": "82172", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.6, "discounted_cash": 21, "minimum": 10.08, "maximum": 61, "payers_information": [ { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.04, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.64, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.04, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.8, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 32.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.31, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.05, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ANOSCOPY HRA W/ BIOPSIES", "code_information": [ { "code": "46607", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2238.1, "discounted_cash": 1531, "minimum": 146.3595, "maximum": 2238.1, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1562.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1782.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 146.36 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2238.1, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1745.96, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2153.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2236.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1801.09, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1782.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2238.1, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1782.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1837.85, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1819.47, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1782.71, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1745.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 4", "code_information": [ { "code": "5474", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25639.21, "maximum": 27433.95, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS", "code_information": [ { "code": "311", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6875, "minimum": 6875.49, "maximum": 24832.6468, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11946.02 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8003.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7013, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8003.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6944.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7838.06, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8938.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6875.49, "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": 6875.49, "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": 12458.39, "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": 9666.94, "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": 10038.22, "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": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8085.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8003.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10657.01, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11000.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8003.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8250.59, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8168.08, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8003.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7930.83 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6875.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11946.02 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7838.06, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APP SK FAC,FT,GEN 1&BDY100SQCM - 15277 - 67052", "code_information": [ { "code": "15277", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7825.8, "discounted_cash": 2640, "minimum": 177.21, "maximum": 8687.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 3374.39, "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": 177.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 186.01 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 189.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3105.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4093.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3168.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3137.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTCRDLPIN ABS,lgA/lgG/lgM*LC1", "code_information": [ { "code": "86147", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.46, "discounted_cash": 25, "minimum": 3.246, "maximum": 132, "payers_information": [ { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.54, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.23, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 32.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.93, "additional_payer_notes": "117.60% of Medicare Rates" } ] } ] }, { "description": "ANTI MULLERIAN HORMONE AMH LC", "code_information": [ { "code": "82397", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42, "discounted_cash": 14, "minimum": 4.398, "maximum": 400, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.04, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.85 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.18, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 19.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.61, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.89, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 3", "code_information": [ { "code": "1983", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6257.77, "maximum": 6695.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APP SK TRK,ARM,GEN ADL 100SQCM", "code_information": [ { "code": "15274", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3720.62, "minimum": 36.49, "maximum": 3720.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 38.47 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTI-68KD ABS", "code_information": [ { "code": "84181", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180.75, "discounted_cash": 17, "minimum": 17.03, "maximum": 180.75, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.76, "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": 17.37 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "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": 17.37 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.41, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 17.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.03, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.37 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.37 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.23, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.41, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIO @ADTL SELECTIVE VESSEL", "code_information": [ { "code": "75774", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2413, "minimum": 87.74, "maximum": 2413, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 363.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTI-COCCIDIODES IMM SER LCORP", "code_information": [ { "code": "86635", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40, "discounted_cash": 11, "minimum": 4.725, "maximum": 74, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.11, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.35, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.98 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "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": 11.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.08, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "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": 11.47, "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": 16.13 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.52 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.35, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.78, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.35, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.76, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.35, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.11, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.08, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTI-JO-1* LC", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18, "discounted_cash": 17, "minimum": 2.319, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 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": 16.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 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": 18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 3", "code_information": [ { "code": "2333", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15997.97, "maximum": 17117.83, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTI-SCLERODERMA-70 AB", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.46, "discounted_cash": 17, "minimum": 2.319, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOGRAPH EXTR RT UNILATERAL", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 234.6, "discounted_cash": 4041, "minimum": 70.38, "maximum": 9197, "payers_information": [ { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 234.6 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "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": 130.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 234.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 } ] } ] }, { "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTI-SM AB", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 65, "discounted_cash": 17, "minimum": 2.319, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 27.79, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.52, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTI-SMOOTH MSCLE AB* LC", "code_information": [ { "code": "86255", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.76, "discounted_cash": 12, "minimum": 2.628, "maximum": 129, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANGIOGRAPHY EXTREMITY BILATERA", "code_information": [ { "code": "75716", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 278.72, "discounted_cash": 4041, "minimum": 83.616, "maximum": 9197, "payers_information": [ { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "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": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 278.72 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "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": 143.37 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "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": 278.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "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": 278.72, "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": 278.72, "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": 278.72, "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": 153.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.72, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "APPENDIX PROCEDURES WITH MCC", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22959, "minimum": 22959.7, "maximum": 42388.46, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42388.46 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26725.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23418.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 22959.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22959.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26725.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 22959.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23189.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26174.09, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22959.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 29847.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22959.73, "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": 22959.73, "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": 41603.03, "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": 32281.38, "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": 33521.21, "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": 22959.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27000.64, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22959.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22959.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 22959.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22959.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22959.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22959.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26725.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 35587.58, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36735.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26725.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27551.68, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27276.16, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22959.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26725.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22959.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34939.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22959.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42388.46 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26174.09, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTITHROMBIN III PANEL,LC", "code_information": [ { "code": "85300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 38.25, "discounted_cash": 11, "minimum": 6.513, "maximum": 38.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.51, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.94, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.22, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.08, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.51, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTIBODY ID-AHG", "code_information": [ { "code": "85240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 159, "discounted_cash": 17, "minimum": 4.5, "maximum": 159, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.87, "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": 18.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.84, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 25.33 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "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": 18.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.85, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.41, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.13 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.05, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.84, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 27.75, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.84, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.84, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.41, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPL ALLOGENIC SKIN SUB 1ST 25", "code_information": [ { "code": "15271", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 670.4, "discounted_cash": 945, "minimum": 72.23, "maximum": 8687.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "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": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 75.81 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "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": 72.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "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": 670.4, "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": 77.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.4, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AORTOGRAM ABDOMINAL", "code_information": [ { "code": "75625", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1645, "discounted_cash": 4041, "minimum": 102.25, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 389.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1645, "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": 102.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1645, "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": 1645, "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": 109.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1645, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTICHROMATIN ANTIBODIES LC", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.93, "discounted_cash": 17, "minimum": 2.319, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Angiotnsion Convrtng.Enzyme*LC", "code_information": [ { "code": "82164", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.73, "discounted_cash": 14, "minimum": 1.719, "maximum": 24.3, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPL SPLINT LEG SHORT*LEFT", "code_information": [ { "code": "29515", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 575.5, "discounted_cash": 207, "minimum": 81.17, "maximum": 696, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 86.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 244.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 247.08, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 81.17 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 85.23 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "AORTOGRAM TRANSLUMBAR", "code_information": [ { "code": "75625", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1612, "discounted_cash": 4041, "minimum": 102.25, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 389.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1612, "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": 102.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1612, "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": 1612, "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": 109.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1612, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE AP&LAT", "code_information": [ { "code": "73600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 172, "discounted_cash": 111, "minimum": 19.92, "maximum": 311.5, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.64 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLIC OF MULT LYR BILAT BLW K", "code_information": [ { "code": "29581", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 696, "discounted_cash": 207, "minimum": 77.81, "maximum": 794.35, "payers_information": [ { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 247.08, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 77.81 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 81.7 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 77.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 83.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 244.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "APP SK FAC NECK,HND ADL100SQCM", "code_information": [ { "code": "15278", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3811, "minimum": 45.42, "maximum": 3811, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 47.52 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 } ] } ] }, { "description": "ANTIVERT - 00378548510", "drug_information": { "unit": 12.5, "type": "ME" }, "code_information": [ { "code": "00378548510", "type": "NDC" }, { "code": "J8597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 8.96, "10th_percentile": 8.96, "90th_percentile": 9.16, "count": "1 through 10" } ] } ] }, { "description": "ANKLE LEFT W/O CONT - 73700 - 71045", "code_information": [ { "code": "73700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1463, "discounted_cash": 133, "minimum": 131.98, "maximum": 1463, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 317.98 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 141.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 131.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLICATION BILATER UNNA BOOT", "code_information": [ { "code": "29580", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1588.7, "discounted_cash": 207, "minimum": 38.99, "maximum": 1588.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 38.99 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 40.94 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 38.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 41.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 38.99 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 244.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.99 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 247.08, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.99 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APP SK FAC,FT,GEN 1&BDY100SQCM - 15277 - 67117", "code_information": [ { "code": "15277", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8687.65, "discounted_cash": 2640, "minimum": 177.21, "maximum": 8687.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 3374.39, "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": 177.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 186.01 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 189.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3105.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4093.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3168.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3137.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AORTA-ILEAL FEMORAL ANGIOGRAM", "code_information": [ { "code": "75630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1482, "discounted_cash": 4041, "minimum": 104.04, "maximum": 9197, "payers_information": [ { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 426.22 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1482, "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": 104.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1482, "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": 1482, "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": 111.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1482, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE LEFT W/O CONT - 73721 - 70961", "code_information": [ { "code": "73721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2800, "discounted_cash": 305, "minimum": 206.2, "maximum": 2800, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 588.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 308.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 348.13, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 429.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 445.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 220.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 359.13, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 473.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 366.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 362.79, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 206.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 348.13, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLICATION UNA BOOT", "code_information": [ { "code": "29580", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 794.35, "discounted_cash": 207, "minimum": 38.99, "maximum": 1588.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 38.99 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 40.94 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 38.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 41.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 38.99 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 244.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.99 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 247.08, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.99 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 2", "code_information": [ { "code": "2342", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9012.97, "maximum": 9643.88, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AORTIC ARCH ANGIOGRAM", "code_information": [ { "code": "36221", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14240, "discounted_cash": 4041, "minimum": 173.86, "maximum": 14240, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "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": 173.86 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 400.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 173.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4606.9, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 186.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 173.86 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4752.38, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.86 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.86 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4849.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4800.87, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.86 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4606.9, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE NERVE BLOCK", "code_information": [ { "code": "64450", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 515, "discounted_cash": 903, "minimum": 70.49, "maximum": 515, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.49 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 74.01 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 515, "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": 70.49 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 515, "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": 515, "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": 75.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 70.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.49 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.49 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 515, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLY SK FAC,FT,GEN ADL 25SQCM - 15276 - 67116", "code_information": [ { "code": "15276", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2962.72, "minimum": 20.48, "maximum": 7825.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 21.27 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPLY SK TR,AR,LGS ADT 25 SQCM - 15272 - 67112", "code_information": [ { "code": "15272", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2223, "minimum": 14.15, "maximum": 7825.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.03 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 } ] } ] }, { "description": "APPENDIX PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11082, "minimum": 11082.28, "maximum": 20207.9, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19225.18 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12899.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11303.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 11082.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11082.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12899.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11082.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11193.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12633.8, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11082.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14406.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11082.28, "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": 11082.28, "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": 20081.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 15581.69, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16180.13, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11082.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13032.76, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11082.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11082.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11082.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11082.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11082.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11082.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12899.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 17177.53, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17731.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12899.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13298.74, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13165.75, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11082.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12899.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11082.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20207.9 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11082.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19225.18 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12633.8, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APNEA MONITOR DAILY", "code_information": [ { "code": "94799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 116, "discounted_cash": 164, "minimum": 34.8, "maximum": 1742, "payers_information": [ { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "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": 116, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 116, "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": 116, "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": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 116, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 1", "code_information": [ { "code": "5471", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4360.09, "maximum": 4665.3, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APS COMP(ESOTERIX) LC", "code_information": [ { "code": "85597", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132.05, "discounted_cash": 17, "minimum": 16.515, "maximum": 132.05, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 25.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 27.87, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.36, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.5, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPL CAST LEG SHORT,RIGHT", "code_information": [ { "code": "29405", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 730, "discounted_cash": 357, "minimum": 107.1, "maximum": 1460, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 122.3 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 128.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 122.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.09, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 130.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 420.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 429.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 425.27, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.09, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APP MUL LYR COMP THIGH&BLW RT", "code_information": [ { "code": "29581", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 575.5, "discounted_cash": 207, "minimum": 77.81, "maximum": 794.35, "payers_information": [ { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 77.81 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 81.7 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 77.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 83.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 244.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 247.08, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPL SK TRK,AR 1ST BDY100SQCM", "code_information": [ { "code": "15273", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17091.3, "discounted_cash": 2640, "minimum": 172, "maximum": 17091.3, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center 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": 3374.39, "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": 172 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 180.57 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 184.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3105.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4093.12, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3168.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3137.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3073.8, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3010.42, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 2", "code_information": [ { "code": "2332", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11244.48, "maximum": 12031.59, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTI-CARDOLIPIN AB LgG/LGM*LC", "code_information": [ { "code": "86147", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.62, "discounted_cash": 25, "minimum": 3.246, "maximum": 132, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "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": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 21.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "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": 20.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "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": 21.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPL SPLINT LEG SHORT,RIGHT", "code_information": [ { "code": "29515", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 348, "discounted_cash": 207, "minimum": 81.17, "maximum": 696, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 81.17 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 85.23 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 81.17 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 86.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 244.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 247.08, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPL SPLINT LEG SHORT,BILAT", "code_information": [ { "code": "29515", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 696, "discounted_cash": 207, "minimum": 81.17, "maximum": 696, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 81.17 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 85.23 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 81.17 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 86.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 244.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 247.08, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTI-DNA ANTIBODY/PAML LC", "code_information": [ { "code": "86225", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.29, "discounted_cash": 13, "minimum": 2.187, "maximum": 116.75, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLIC OF MULT LYR BLW KNEE RT", "code_information": [ { "code": "29581", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 794.35, "discounted_cash": 207, "minimum": 77.81, "maximum": 794.35, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 77.81 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 81.7 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 77.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 83.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 244.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 247.08, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLIC OF MULTI LAYR*LT BLW KN", "code_information": [ { "code": "29581", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 794.35, "discounted_cash": 207, "minimum": 77.81, "maximum": 794.35, "payers_information": [ { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 322.37, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 249.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 247.08, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 77.81 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 81.7 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 77.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.1, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 83.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 244.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.09, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ANTI-DNA(SS)IGG,AB* LC", "code_information": [ { "code": "86226", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.46, "discounted_cash": 12, "minimum": 5.538, "maximum": 18.46, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.35 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.91 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "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": 12.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.17, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.81, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.24, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.35 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.46, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.53, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.81, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLIC SK LRG (1ST 100 SQCM)", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1926.7, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLIC SK SM**EA ADL 25 SQCM", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 466.2, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Anti-Extractable Nuclear AG*LC", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.07, "discounted_cash": 17, "minimum": 2.319, "maximum": 103.25, "payers_information": [ { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "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": 16.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "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": 16.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ART W/EX-LIMITED/LWR", "code_information": [ { "code": "93926", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1221, "discounted_cash": 133, "minimum": 104.72, "maximum": 1672, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 127.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLIC SK LRG*(EA ADL 100SQCM)", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1265.15, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLY FOREARM SPLINT", "code_information": [ { "code": "29125", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 559.75, "discounted_cash": 170, "minimum": 75.84, "maximum": 559.75, "payers_information": [ { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 79.63 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Anti-Glomerular BM,AB* LC", "code_information": [ { "code": "83520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.79, "discounted_cash": 17, "minimum": 3.942, "maximum": 690, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.69, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.31, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.72, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.69, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIAL BLOOD GAS-PANEL", "code_information": [ { "code": "82803", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130.35, "discounted_cash": 26, "minimum": 13.6, "maximum": 325, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.35, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 27.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 39.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.72, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 36.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 36.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.06 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.55 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.66, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.35, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 40.41, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.35, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.28, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.97, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.35, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.72, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLY SK FAC,FT,GEN ADL 25SQCM - 15276 - 67050", "code_information": [ { "code": "15276", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7825.8, "minimum": 20.48, "maximum": 7825.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 21.27 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 } ] } ] }, { "description": "Anti-Nuclear AB-Direct*LC", "code_information": [ { "code": "86038", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.27, "discounted_cash": 12, "minimum": 1.248, "maximum": 105, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.78, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.22, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.74, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.51, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.36, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.07, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.78, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM CELIAC", "code_information": [ { "code": "75726", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1535, "discounted_cash": 7121, "minimum": 121.45, "maximum": 7360, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1535, "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": 121.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1535, "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": 1535, "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": 129.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLY SHORT LEG CAST", "code_information": [ { "code": "29405", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 357, "discounted_cash": 357, "minimum": 107.1, "maximum": 1460, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_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, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 128.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 357, "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": 122.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 357, "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": 357, "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": 130.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 357, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLY SK FAC,HND,GEN1ST 25SQCM - 15275 - 67115", "code_information": [ { "code": "15275", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8687.65, "discounted_cash": 945, "minimum": 83.02, "maximum": 8687.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 87.24 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 83.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1078.34, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 88.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1112.39, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1466.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1135.09, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1123.74, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1078.34, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTICHROMATIN AB", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.72, "discounted_cash": 17, "minimum": 2.319, "maximum": 103.25, "payers_information": [ { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM LEFT CAROTID", "code_information": [ { "code": "36223", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1654, "discounted_cash": 7121, "minimum": 256.89, "maximum": 4416, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 406.08 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1654, "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": 256.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1654, "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": 1654, "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": 274.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLY SK TR,AR,LGS ADT 25 SQCM - 15272 - 67049", "code_information": [ { "code": "15272", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7825.8, "minimum": 14.15, "maximum": 7825.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.03 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 } ] } ] }, { "description": "ARTERIOGRAM LEFT RENAL", "code_information": [ { "code": "36251", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8022.99, "discounted_cash": 4041, "minimum": 227.85, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "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": 227.85 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 239.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 227.85 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4606.9, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 243.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4752.38, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6263.77, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4849.37, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4800.87, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4703.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4606.9, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIAL BLOOD GAS W/COOX-PANE", "code_information": [ { "code": "82805", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 325, "discounted_cash": 78, "minimum": 27.88, "maximum": 325, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 103.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 100.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 91.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 40.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "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": 27.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 118.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 79.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.8, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 110.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "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": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 110.75 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 115 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 27.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 92.63, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.88 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.88 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 91.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 122.09, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 91.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 94.52, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 93.58, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 91.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 103.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.8, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLY SKTRK,ARM,LEG 1ST 25SQCM - 15271 - 67111", "code_information": [ { "code": "15271", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8687.65, "discounted_cash": 945, "minimum": 72.23, "maximum": 8687.65, "payers_information": [ { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1078.34, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 77.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1112.39, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1466.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1135.09, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1123.74, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1078.34, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 75.81 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 72.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC", "code_information": [ { "code": "268", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 65550, "minimum": 18126.1, "maximum": 118776.9805, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 114064.61 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76300.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 66861.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 65550.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 65550.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76300.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 65550.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 66205.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74727.24, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 65550.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 85215.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 65550.21, "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": 65550.21, "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": 118776.98, "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": 92163.6, "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": 95703.31, "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": 65550.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77087.05, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 65550.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 65550.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 65550.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 65550.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 65550.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 65550.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76300.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 101602.83, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 104880.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76300.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78660.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77873.65, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 65550.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76300.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 65550.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18126.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 65550.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 114064.61 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74727.24, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM MESSENTERIC", "code_information": [ { "code": "75726", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1535, "discounted_cash": 7121, "minimum": 121.45, "maximum": 7360, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1535, "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": 121.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1535, "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": 1535, "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": 129.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Arterial DPLR Lower Ext Bilat", "code_information": [ { "code": "93925", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1672, "discounted_cash": 305, "minimum": 104.21, "maximum": 1672, "payers_information": [ { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 348.13, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 145.9 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 308.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 348.13, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 429.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 445.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 359.13, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 473.34, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 366.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 362.79, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 355.46, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "APP SK FAC,HND,GEN ADL100SQCM", "code_information": [ { "code": "15278", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1265.15, "minimum": 45.42, "maximum": 3811, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 47.52 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 } ] } ] }, { "description": "ARTERIOGRAM PULMONARY BILATERA", "code_information": [ { "code": "75743", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2445, "discounted_cash": 4041, "minimum": 104.21, "maximum": 2445, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 405.78 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2445, "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": 104.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2445, "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": 2445, "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": 111.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2445, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIAL DUPLEX LOWER EXTRE", "code_information": [ { "code": "93926", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1672, "discounted_cash": 133, "minimum": 104.72, "maximum": 1672, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 127.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ARTERIOGRAM RENAL BILATERAL", "code_information": [ { "code": "36252", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2130, "discounted_cash": 4041, "minimum": 296.72, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 296.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 311.37 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2130, "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": 296.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2130, "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": 2130, "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": 317.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 296.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 296.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 296.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 296.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2130, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIAL DUPLEX UPPER EXTREM", "code_information": [ { "code": "93931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1672, "discounted_cash": 133, "minimum": 93.89, "maximum": 1672, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.79 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 100.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTER PHYS LO EXT BILAT SINGLE", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 549, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 1", "code_information": [ { "code": "2341", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7065.57, "maximum": 7560.16, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ARTERIOGRAM RIGHT RENAL", "code_information": [ { "code": "36251", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1724, "discounted_cash": 4041, "minimum": 227.85, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 239.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1724, "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": 227.85 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1724, "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": 1724, "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": 243.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM CAROTID UNILAT", "code_information": [ { "code": "36223", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1654, "discounted_cash": 7121, "minimum": 256.89, "maximum": 4416, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 274.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 406.08 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1654, "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": 256.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1654, "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": 1654, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIAL DUPL W/O EX-LTD UPPER", "code_information": [ { "code": "93931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1131, "discounted_cash": 133, "minimum": 93.89, "maximum": 1672, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 124.79 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 100.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPENDIX PROCEDURES WITH CC", "code_information": [ { "code": "398", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14587, "minimum": 14587, "maximum": 31417, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25886.76 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16979.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14878.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16979.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14732.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16629.18, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 18963.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26431.64, "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": 20509.32, "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": 21297.02, "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": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17154.31, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16979.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 22609.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23339.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16979.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17504.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17329.36, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16979.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31417 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25886.76 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16629.18, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM SELECTIVE 1VESSEL", "code_information": [ { "code": "75774", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1582, "minimum": 87.74, "maximum": 2413, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 363.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 } ] } ] }, { "description": "ARTERIOGRAM CEREBRAL 3VESSEL", "code_information": [ { "code": "36221", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2265, "discounted_cash": 4041, "minimum": 173.86, "maximum": 14240, "payers_information": [ { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.86 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 400.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2265, "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": 173.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2265, "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": 2265, "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": 186.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 173.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.86 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.86 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 173.86 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2265, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM CAROTID BILATERAL", "code_information": [ { "code": "36223", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2126, "discounted_cash": 7121, "minimum": 256.89, "maximum": 4416, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 406.08 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2126, "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": 256.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2126, "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": 2126, "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": 274.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2126, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPL ALLOGENIC SKIN SUB ADD 25", "code_information": [ { "code": "15272", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 670.4, "minimum": 14.15, "maximum": 7825.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.03 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 } ] } ] }, { "description": "ARTHOGRAM RIGHT JOINT SPECIFIC", "code_information": [ { "code": "73115", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 44.26, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 44.26 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 47.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM FEMORAL BILATERAL", "code_information": [ { "code": "75716", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1587, "discounted_cash": 4041, "minimum": 83.616, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 394.45 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1587, "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": 143.37 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1587, "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": 1587, "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": 153.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1587, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM FEMORAL UNILAT", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1334, "discounted_cash": 4041, "minimum": 70.38, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 130.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 1334, "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": 140 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPL CAST LEG SHORT, LEFT", "code_information": [ { "code": "29405", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 794.35, "discounted_cash": 357, "minimum": 107.1, "maximum": 1460, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 122.3 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 128.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 122.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.09, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 130.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 420.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 429.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 425.27, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.09, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM HEPATIC", "code_information": [ { "code": "75726", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1535, "discounted_cash": 7121, "minimum": 121.45, "maximum": 7360, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1535, "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": 121.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1535, "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": 1535, "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": 129.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM LEFT EXT", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1334, "discounted_cash": 4041, "minimum": 70.38, "maximum": 9197, "payers_information": [ { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 130.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 1334, "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": 140 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "120.00% of Medicare Rates" } ] } ] }, { "description": "APPL CAST LEG SHORT,BILATERAL", "code_information": [ { "code": "29405", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1460, "discounted_cash": 357, "minimum": 107.1, "maximum": 1460, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "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": 122.3 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 128.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 122.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.09, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 130.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 420.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 554.85, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 429.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 425.27, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.09, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM OPERATIVE", "code_information": [ { "code": "76499", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 351, "discounted_cash": 111, "minimum": 8.4, "maximum": 973, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 130.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 172.62, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 133.64, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 132.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 129.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM LEFT FEMORAL", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1334, "discounted_cash": 4041, "minimum": 70.38, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 130.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 1334, "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": 140 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLIC SKIN SM(25-100)1ST 25sq", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1265.15, "discounted_cash": 170, "minimum": 50.82, "maximum": 1926.7, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 200.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 263.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 204.34, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 202.29, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 198.21, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 194.12, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM RENAL UNILAT", "code_information": [ { "code": "36251", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1724, "discounted_cash": 4041, "minimum": 227.85, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 239.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1724, "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": 227.85 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1724, "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": 1724, "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": 243.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1724, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM PANCREATIC", "code_information": [ { "code": "75726", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1535, "discounted_cash": 7121, "minimum": 121.45, "maximum": 7360, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1535, "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": 121.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1535, "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": 1535, "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": 129.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1535, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM PULMONARY UNILAT", "code_information": [ { "code": "75741", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2131, "discounted_cash": 4041, "minimum": 102.44, "maximum": 9197, "payers_information": [ { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 394.17 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2131, "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": 102.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2131, "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": 2131, "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": 109.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2131, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM RIGHT CAROTID", "code_information": [ { "code": "36223", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1654, "discounted_cash": 7121, "minimum": 256.89, "maximum": 4416, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 406.08 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1654, "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": 256.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1654, "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": 1654, "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": 274.87 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1654, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLY SK FAC,HND,GEN1ST 25SQCM - 15275 - 67048", "code_information": [ { "code": "15275", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7825.8, "discounted_cash": 945, "minimum": 83.02, "maximum": 8687.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 87.24 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 83.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1078.34, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 88.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1112.39, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1466.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1135.09, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1123.74, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1078.34, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM RIGHT FEMORAL", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1334, "discounted_cash": 4041, "minimum": 70.38, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 130.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 1334, "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": 140 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APPLY SKTRK,ARM,LEG 1ST 25SQCM - 15271 - 67047", "code_information": [ { "code": "15271", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7825.8, "discounted_cash": 945, "minimum": 72.23, "maximum": 8687.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "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": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 75.81 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "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": 72.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1078.34, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA 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": 77.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "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": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1112.39, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A 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": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1466.16, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1135.09, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1123.74, "additional_payer_notes": "118.80% 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": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1101.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network 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" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1078.34, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Artery-vein autograft", "code_information": [ { "code": "36825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32736, "discounted_cash": 7121, "minimum": 886.49, "maximum": 32736, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "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": 886.49 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7264.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8289.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 930.81 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "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": 886.49 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8118.83, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9970.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10013.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10397.8, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 948.54 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8375.21, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8289.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11038.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8289.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8546.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8460.67, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8289.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 886.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8118.83, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "APRESOLINE IV", "drug_information": { "unit": 1, "type": "ML" }, "code_information": [ { "code": "63323061401", "type": "NDC" }, { "code": "J0360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 40.4, "median_amount": 72.25, "10th_percentile": 72.25, "90th_percentile": 72.25, "count": "1 through 10" } ] } ] }, { "description": "ARTHROCENT ASP/INJ JT,SMALL", "code_information": [ { "code": "20600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 742, "discounted_cash": 392, "minimum": 46.46, "maximum": 1084.85, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 48.78 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 447.86, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.71 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 462, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.43, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 466.72, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 447.86, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Artery-vein nonautograft", "code_information": [ { "code": "36830", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35856, "discounted_cash": 7121, "minimum": 834.68, "maximum": 35856, "payers_information": [ { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8118.83, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "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": 834.68 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7264.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8289.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 876.41 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "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": 834.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8118.83, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9970.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10013.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10397.8, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 893.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8375.21, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8289.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11038.76, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8289.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8546.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8460.67, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8289.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 834.68 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ARTHROGRAM HIP", "code_information": [ { "code": "73525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 78.84, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 113.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 78.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 84.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTHROGRAM JOINT SPECIFY", "code_information": [ { "code": "73115", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 44.26, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 44.26 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 47.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTHROCENT ASP/INJ JT,MAJOR", "code_information": [ { "code": "20610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1237.4, "discounted_cash": 392, "minimum": 65.68, "maximum": 1237.4, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 68.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 447.86, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 462, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.43, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 466.72, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 447.86, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTHROGRAM RIGHT HIP", "code_information": [ { "code": "73525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 78.84, "maximum": 541, "payers_information": [ { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 113.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 78.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 84.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" } ] } ] }, { "description": "ARTHROGRAM KNEE", "code_information": [ { "code": "73580", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 76.45, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 104.25 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 76.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 81.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Arsenic, Blood", "code_information": [ { "code": "82175", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 94.85, "discounted_cash": 18, "minimum": 18.97, "maximum": 94.85, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.87 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.63, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.67 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.31, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 29.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.76, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.54, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.63, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTHROGRAM RIGHT KNEE", "code_information": [ { "code": "73580", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 76.45, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 104.25 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 76.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 81.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTHRITIS SURVEY", "code_information": [ { "code": "77077", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 619, "discounted_cash": 133, "minimum": 19.27, "maximum": 619, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.27 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 34.89 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.27 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.27 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.27 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.27 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTHROGRAM LEFT HIP", "code_information": [ { "code": "73525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 78.84, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 113.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 78.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 84.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ART DUPLEX W/O EX-LMTD/LWR", "code_information": [ { "code": "93926", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1131, "discounted_cash": 133, "minimum": 104.72, "maximum": 1672, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 127.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 157.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 207.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 160.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 158.95, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 155.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTHROCENT ASP/INJ JT,INTERMED", "code_information": [ { "code": "20605", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1237.4, "discounted_cash": 392, "minimum": 54.46, "maximum": 1237.4, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.43, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 466.72, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 447.86, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 57.18 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 447.86, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 462, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.46 } ] } ] }, { "description": "ARTHROGRAM RIGHT SHOULDER", "code_information": [ { "code": "73040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 53.81, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 76.35 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 53.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 57.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIAL LINE", "code_information": [ { "code": "36620", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5500, "minimum": 60.35, "maximum": 5500, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 63.37 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 64.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 } ] } ] }, { "description": "ARTHROGRAM LEFT SHOULDER", "code_information": [ { "code": "73040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 53.81, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 76.35 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 53.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 57.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTHROGRAM SHOULDER", "code_information": [ { "code": "73040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 53.81, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 76.35 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 53.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 57.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 525.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 535.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 530.44, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY IGA/IGD/IGG/IGM EA LC", "code_information": [ { "code": "82784", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.43, "discounted_cash": 9, "minimum": 1.152, "maximum": 62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.94, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 } ] } ] }, { "description": "ASPIRATION ABCS/HEMA/BULLA", "code_information": [ { "code": "10160", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 448, "discounted_cash": 520, "minimum": 67.29, "maximum": 1997.65, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 70.65 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 448, "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": 67.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 448, "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": 448, "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": 72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 67.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.29 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.29 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.29 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 448, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM EXTREMITY", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1334, "discounted_cash": 4041, "minimum": 70.38, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 130.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 1334, "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": 140 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASPERGILLUS AG BAL/SERUM LC", "code_information": [ { "code": "87305", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.5, "discounted_cash": 11, "minimum": 6.93, "maximum": 59.5, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.57, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.23, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.66, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.09 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.66, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.09, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY MERCURY LC", "code_information": [ { "code": "83825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.25, "discounted_cash": 16, "minimum": 4.875, "maximum": 16.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM RIGHT EXT", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1334, "discounted_cash": 4041, "minimum": 70.38, "maximum": 9197, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 130.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1334, "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": 1334, "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": 140 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1334, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASPIRATE/INJECT GANGLION CYST", "code_information": [ { "code": "20612", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 822, "discounted_cash": 392, "minimum": 54.36, "maximum": 822, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 57.08 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 447.86, "additional_payer_notes": "114.00% 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 NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.17 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 462, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 608.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.43, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 466.72, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 447.86, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY PHENYTOIN TOTAL", "code_information": [ { "code": "80185", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.25, "discounted_cash": 13, "minimum": 1.875, "maximum": 81, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY ALKALINE PHOSPHATE LC", "code_information": [ { "code": "84075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.54, "discounted_cash": 5, "minimum": 4.662, "maximum": 37, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.85 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "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": 4.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.91, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.56 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.09, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.03, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.22, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.15, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.91, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM SELECTIVE 2VESSEL", "code_information": [ { "code": "75774", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1853, "minimum": 87.74, "maximum": 2413, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 363.38 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 } ] } ] }, { "description": "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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASSAY OF G6PD ENZYME", "code_information": [ { "code": "82955", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.67, "discounted_cash": 9, "minimum": 1.101, "maximum": 3.67, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ARTERIOGRAM SHUNT DIALYSIS", "code_information": [ { "code": "36901", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1050, "discounted_cash": 2014, "minimum": 106.95, "maximum": 4312.55, "payers_information": [ { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 518.24 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 518.24 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 518.24 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 518.24 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 544.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1050, "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": 518.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1050, "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": 1050, "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": 554.52 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 518.24 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1050, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ATHERECT TIBIOPERONEAL PERC", "code_information": [ { "code": "37229", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 22494, "minimum": 643.9125, "maximum": 44975.1, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 643.91 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY SALICYLATE LC", "code_information": [ { "code": "80179", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.93, "discounted_cash": 18, "minimum": 1, "maximum": 310.7, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY AORTIC PERC - 0236T - 95596", "code_information": [ { "code": "0236T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 14775, "minimum": 3772.98, "maximum": 35791.4, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASSAY IGA/IGD/IGG/IGM EA", "code_information": [ { "code": "82784", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.02, "discounted_cash": 9, "minimum": 1.152, "maximum": 62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.08 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.94, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.42, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 } ] } ] }, { "description": "ATHERECTOMY BRACHIOCEPHA PERC - 0237T - 95599", "code_information": [ { "code": "0237T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 14775, "minimum": 3772.98, "maximum": 35791.4, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AT ANTIGEN IMMUNOLOGIC LC", "code_information": [ { "code": "85301", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.15, "discounted_cash": 10, "minimum": 2.445, "maximum": 16.54, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY OF PROTEIN URINE", "code_information": [ { "code": "84156", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.35, "discounted_cash": 3, "minimum": 1, "maximum": 18.35, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.51, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.18, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.32, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.69, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.36, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.18, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY ILIAC PERC", "code_information": [ { "code": "0238T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 23462, "minimum": 3772.98, "maximum": 35791.4, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY OF PSA FREE LC", "code_information": [ { "code": "84154", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.88, "discounted_cash": 18, "minimum": 1.464, "maximum": 110, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY RENAL PERC - 0234T - 95595", "code_information": [ { "code": "0234T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12576.6, "discounted_cash": 14775, "minimum": 564.6, "maximum": 35791.4, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "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": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12576.6, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY AORTIC OPEN", "code_information": [ { "code": "0236T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35791.4, "discounted_cash": 14775, "minimum": 3772.98, "maximum": 35791.4, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17198.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 22901.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17198.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17730, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17552.7, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17198.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16843.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15070.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17198.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22162.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14922.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16843.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20685, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20773.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21571.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17375.4, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY OF SERUM ALBUMIN LC", "code_information": [ { "code": "82040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.43, "discounted_cash": 4, "minimum": 1, "maximum": 37, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.64, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.96 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.67, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.94, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.88, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.64, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6602, "minimum": 6258.66, "maximum": 18766.2022, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11502.95 }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7685.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6734.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7685.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6668.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7527.23, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8583.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6602.83, "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": 6602.83, "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": 11964.33, "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": 9283.58, "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": 9640.13, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7764.93, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7685.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "case rate", "standard_charge_dollar": 10234.39, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10564.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7685.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7923.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7844.16, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7685.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6258.66 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6602.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11502.95 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7527.23, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY EA ADD VESSEL-LAD", "code_information": [ { "code": "92925", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2877.56, "minimum": 863.268, "maximum": 17964.1, "payers_information": [ { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1060.85 } ] } ] }, { "description": "ASSAY PHENOBARBITAL", "code_information": [ { "code": "80184", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.25, "discounted_cash": 15, "minimum": 1, "maximum": 15.3, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY ILIAC PERC W/S&I", "code_information": [ { "code": "0238T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35791.4, "discounted_cash": 23462, "minimum": 3772.98, "maximum": 35791.4, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27591.32, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27309.78, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 35791.4, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27309.78, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28154.41, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27872.87, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27309.78, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30907.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26746.69, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30907.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23931.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27309.78, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 35193.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23696.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26746.69, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 32846.81, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 32987.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34254.53, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY RBC PROTOPORHYRIN LC", "code_information": [ { "code": "84202", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.01, "discounted_cash": 14, "minimum": 2.103, "maximum": 7.01, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AUD PURE TONE AUDIOMETRY AUTO - 0209T - 13814", "code_information": [ { "code": "0209T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.25, "discounted_cash": 47, "minimum": 30.975, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.48, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.2, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 57.35, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.77, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.48, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AUD COMPR AUTOMETRY EVAL SPCH", "code_information": [ { "code": "0212T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 183.25, "discounted_cash": 164, "minimum": 54.975, "maximum": 183.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "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": 167.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "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": 166.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 183.25, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY URINE CREATININE LC", "code_information": [ { "code": "82570", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.18, "discounted_cash": 5, "minimum": 1, "maximum": 50, "payers_information": [ { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "AUD SPCH AUDIOMETRY THRSHLD", "code_information": [ { "code": "0210T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.25, "discounted_cash": 47, "minimum": 30.975, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.48, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.2, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 57.35, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.77, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.48, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AUD PURE TONE AUDIOMETRY AUTO - 0208T - 13813", "code_information": [ { "code": "0208T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.25, "discounted_cash": 47, "minimum": 30.975, "maximum": 103.25, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.48, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.2, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.07, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 57.35, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.77, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.63, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.48, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSESSMENT OF APHASIA PER HOUR", "code_information": [ { "code": "96105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 809, "discounted_cash": 105, "minimum": 73.44, "maximum": 809, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 135.22, "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": 73.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 107.94, "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": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 123.17, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "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": 73.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 158.73, "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": 106.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 120.63, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 148.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "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": 105.82, "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": 148.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 154.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 73.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 124.44, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.44 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.44 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "Multiplan Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 123.17, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Naphcare", "plan_name": "Naphcare Prison", "methodology": "fee schedule", "standard_charge_dollar": 164.02, "additional_payer_notes": "155.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES", "plan_name": "Prime Health Services Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 123.17, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "Provider Network of America Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 126.98, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 125.71, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "Three Rivers Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 123.17, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 120.63, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 2", "code_information": [ { "code": "0082", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 34562.44, "maximum": 36981.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue 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": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "L.A Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ARTHROGRAM LEFT JOINT SPECIFIC", "code_information": [ { "code": "73115", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 541, "discounted_cash": 446, "minimum": 44.26, "maximum": 541, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CENTER", "plan_name": "CA Foundation for Medical Center Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 519.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Anthem Blue cross ", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "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": 44.26 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 541, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "HEALTH NET FEDERAL SERVICES TRICARE", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 541, "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": 541, "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": 47.36 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare",